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“Employment and arthritis: making it work” a randomized controlled trial evaluating an online program… Carruthers, Erin C; Rogers, Pamela; Backman, Catherine L; Goldsmith, Charles H; Gignac, Monique A; Marra, Carlo; Village, Judy; Li, Linda C; Esdaile, John M; Lacaille, Diane Jul 21, 2014

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STUDY PROTOCOL Open Access“Employment and arthritis: making it work” aeffect on at-work productivity, and multivariable Cox regression models will estimate the risk of work cessation associatedCarruthers et al. BMC Medical Informatics and Decision Making 2014, 14:59, BC V6X 2C7, CanadaFull list of author information is available at the end of the articlewith the intervention after controlling for risk factors for WD and other important predictors imbalanced at baseline.Discussion: This program fills an important gap in arthritis health services and addresses an important and costlyproblem. Knowledge gained from the RCT will be useful to health care professionals, policy planners and arthritisstakeholders.Trial registration: NCT01852851; registered April 13, 2012; first participant randomized on July 6, 2013.Keywords: Inflammatory arthritis, Employment, Worker productivity, Work disability, eLearning program,Self-management, Ergonomics, Vocational counselling, Health education, Health promotion* Correspondence: dlacaille@arthritisresearch.ca1Arthritis Research Centre of Canada, 5591 No. 3 Rd, Richmond, BC V6X 2C7,Canada8Division of Rheumatology, University of British Columbia, 5591 No. 3 Rd,randomized controlled trial evaluating an onlineprogram to help people with inflammatoryarthritis maintain employment (study protocol)Erin C Carruthers1, Pamela Rogers1, Catherine L Backman1,2, Charles H Goldsmith1,3, Monique A Gignac4,Carlo Marra5, Judy Village6, Linda C Li1,7, John M Esdaile1,8 and Diane Lacaille1,8*AbstractBackground: Arthritis and musculoskeletal conditions are the leading cause of long-term work disability (WD), anoutcome with a major impact on quality of life and a high cost to society. The importance of decreased at-workproductivity has also recently been recognized. Despite the importance of these problems, few interventions havebeen developed to reduce the impact of arthritis on employment. We have developed a novel intervention called“Making It Work”, a program to help people with inflammatory arthritis (IA) deal with employment issues, preventWD and improve at-work productivity. After favorable results in a proof-of-concept study, we converted theprogram to a web-based format for broader dissemination and improved accessibility. The objectives of this studyare: 1) to evaluate in a randomized controlled trial (RCT) the effectiveness of the program at preventing workcessation and improving at-work productivity; 2) to perform a cost-utility analysis of the intervention.Methods/Design: 526 participants with IA will be recruited from British Columbia, Alberta, and Ontario in Canada.The intervention consists of a) 5 online group sessions; b) 5 web-based e-learning modules; c) consultations with anoccupational therapist for an ergonomic work assessment and a vocational rehabilitation counselor. Questionnaires willbe administered online at baseline and every 6 months to collect information about demographics, disease measures,costs, work-related risk factors for WD, quality of life, and work outcomes. Primary outcomes include at-work productivityand time to work cessation of > 6 months for any reason. Secondary outcomes include temporary work cessation,number of days missed from work per year, reduction in hours worked per week, quality adjusted life year for the costutility analysis, and changes from baseline in employment risk factors. Analysis of Variance will evaluate the intervention’s© 2014 Carruthers et al.; licensee BioMed CenCreative Commons Attribution License (http:/distribution, and reproduction in any mediumDomain Dedication waiver (http://creativecomarticle, unless otherwise stated.tral Ltd. This is an Open Access article distributed under the terms of the/, which permits unrestricted use,, provided the original work is properly credited. The Creative Commons applies to the data made available in thisCarruthers et al. BMC Medical Informatics and Decision Making 2014, 14:59 Page 2 of 7 disability (WD) is a common and early outcome ofinflammatory arthritis (IA), with a major impact on qualityof life and a high cost to those affected, their families and so-ciety [1,2]. Arthritis and musculoskeletal conditions are theleading cause of long-term WD in many countries, includ-ing Canada and the US [3,4]. Recent studies have also drawnattention to the importance of decreased productivity whileat work, or presenteeism [5]. Despite the importance of theproblem, there has been little research on interventions toreduce the impact of arthritis on employment [6-9]. Lack ofemployment services has also been identified by people liv-ing with arthritis as an important unmet need in qualitativestudies [10-12]. It represents an important gap from a clin-ical care and a health services research perspective.To close this care gap, we have developed and pilot testeda novel intervention targeting employed people with IA, toprevent WD and improve at-work productivity [13]. Our“Employment and Arthritis: Making It Work Program” isunique in that it combines the benefits of group sessionsand self-learning modules aimed at enhancing self-management of work-related problems, and individualizedassessments by employment-related health professionals,including an ergonomic assessment by an occupationaltherapist (OT) and job retention vocational rehabilitationcounselling (VRC). Program development was based on astrong theoretical background, the self-management ap-proach proven effective in arthritis management [14,15]and the precede-proceed model [16-18], a validated modelsuccessfully used for developing health education programs.Program content was selected to modify known risk factorsfor WD and problems at work identified in initial focusgroups [10]. A proof of concept study of the interventionshowed favourable results after 12 months of follow up[13]. The program has now been converted to a web-based format to allow broader dissemination of the pro-gram, and to address feedback from participants whofound it difficult to attend sessions at the end of a workday, given the fatigue and difficulty commuting associatedwith their IA. This evolution is consistent with recenttrends in adult learning, health education and in self-management programs [19-31].The objectives of this study are: 1) to evaluate, in a ran-domized controlled trial (RCT), the effectiveness of the pro-gram at preventing work cessation and improving at-workproductivity compared to a control group receiving usualcare; 2) to perform a cost-utility analysis of the intervention.Methods/designStudy designOur study design is consistent with CONSORT recom-mendations for RCTs, 2010 update [32] and extensionfor trials of non-pharmacological treatments [33]. Partic-ipants will be stratified by location and arthritis type andrandomized 1:1 to receive either our program, or “usualcare” as initiated by their physician and supplementedby printed material about work and arthritis. Partici-pants will be followed for 5 years, the estimated time re-quired, according to our power calculations, to observea difference in work cessation similar to that in Allaire’sRCT [34]. After 2 years, analysis of our first primary out-come, at-work productivity, will be performed, alongwith an interim analysis of the second primary outcome,work cessation. If a significant difference in work cessa-tion is observed between the two groups, the RCT willbe terminated prematurely. Because of the nature of theintervention, participants cannot be blinded. Ethics ap-proval was obtained from the University of BritishColumbia Research Ethics Board (H11-03527).Study sample526 participants will be recruited from British Columbia,Alberta, and Ontario. To be eligible to participate, individ-uals must: 1) have a physician confirmed diagnosis of IA(including rheumatoid arthritis, psoriatic arthritis, sys-temic lupus erythematosus, or spondyloarthropathies); 2)Be between the ages of 18 and 59 years; 3) Be able to readand write in English without the assistance of a translator;4) Be currently employed (full time, part time, self-employed, or contract work); 5) Be at risk of job loss, de-fined as answering yes to: “Do you have any concern aboutyour arthritis affecting your ability to work now, or in thenext five years?”; 6) Have access to a personal computerwith high-speed, wired-in internet connection and haveaccess to, or willingness to purchase, a webcam and head-set for the virtual group meetings and VRC assessments;7) Be willing to travel for one visit with an OT.RandomizationRandomization will be stratified by study centre (3 levels)and type of arthritis (4 levels). In each stratum, we will useblocked randomization, with random and variable blocksizes, to ensure optimal balance between trial arms, whileavoiding the risk of study personnel ‘guessing’ the next al-location. Randomization will be performed centrally, inVancouver; by the biostatistician (CG) using a customizedprogram in the R programming language, after the studycoordinator has confirmed eligibility and received informedconsent. To ensure concealment of the randomization listfrom those making eligibility decisions, allocations will beavailable for one patient at a time.InterventionThe intervention consists of three components:1) Five interactive web-based eLearning modules,completed individually by participants in between thebiweekly group sessions. The modules cover relevantCarruthers et al. BMC Medical Informatics and Decision Making 2014, 14:59 Page 3 of 7 such as work and arthritis, management ofIA, dealing with fatigue and stress at work, effectivecommunications skills, disclosing one’s arthritisdiagnosis, optimizing interpersonal relationships atwork, job accommodations, and vocational counselling.In addition to providing didactic information, reflectiveexercises improve self-awareness and allow participantsto apply the concepts learned to their own personalsituation. Self-management techniques and otherrelevant skills are also taught and practiced.2) Five 2-hour biweekly group sessions conducted asvirtual real-time group meetings, with 10–12participants per group, led by a facilitator withknowledge of arthritis and experience leadingself-management or education programs. The groupinteractions allow participants to share experiences,learn from each other, practice skills, and report backto the group on the progress of their action plans.These interactions were highly valued by participantsof our pilot test, who described experiencing validationby hearing from others living similar situations, benefit-ing from others’ experiences and solutions, receivingpeer support, and being motivated to implementchanges by having to report back to the group [13].3) Consultations with an OT and a VRC. Aftercompleting the web-based modules and groupmeetings, participants have an in-person consultationwith an OT for an ergonomic assessment of theirwork. The OT uses a standardized tool we developedfor people with IA called the Ergonomic AssessmentTool for Arthritis (EATA) [35], to identify ergonomicproblems and risks, and recommend ergonomicmodifications as job accommodations. A telephonefollow-up is performed one month later to discussimplementation of recommendations and helpovercome barriers. A vocational counsellor provides“job retention” VRC, using a standardized guidedeveloped for our program, with an initial consultationperformed using web technology and a follow-up onemonth later by telephone. The assessment focuses onidentifying problems at work and developing solutions,evaluating the need for job accommodations andhelping in the process of requesting and obtainingjob accommodations, short and long-term planningsuch as determining if additional training wouldfacilitate long-term goals, as well as discussingindividual issues such as the decision to discloseone’s arthritis, or dealing with interpersonaldifficulties with co-workers or supervisors.Control groupThe control group will receive printed materials providinginformation about arthritis and employment available fromarthritis websites and non-profit organizations. They willalso receive “usual care” from their physicians and alliedhealth professionals. Data will be collected, in follow-up as-sessments, on information and support received to addressemployment issues. To minimize loss to follow-up, all con-trols will be offered the intervention at study end.Data collectionData will be collected on demographics, disease variables,co-morbidities, quality of life, costs, work-related risk fac-tors for WD, and work outcomes, using a self-administeredonline questionnaire. Work outcomes, costs and quality oflife will be assessed every 6 months, and other data onceyearly. To evaluate co-interventions received in bothgroups, data will also be collected every 6 months about IAtreatment received, “usual care” received from physiciansand allied health professionals, information sought aboutemployment issues, use of services specifically targeted atemployment, and job accommodations made.Outcome measuresPrimary work outcomesThe first primary outcome will be presenteeism, or at-work productivity, measured over 2 years, using theWork Instability Scale (WIS-RA) [36]. Developed forRA, the WIS measures mismatch between functionalability and work demands, and was designed to identifyindividuals at high risk of work loss warranting referralfor vocational assessment. It has been shown to havegood psychometric properties, including construct valid-ity [37], and be effective at predicting future work transi-tions [38]. However, a drawback of the WIS is that it doesnot permit the calculation of associated costs. Therefore,for the purpose of the cost-utility analysis, at-work prod-uctivity will be measured using the Work Productivity andActivity Impairment – Specific Health Problem (WPAI-SHP) scale [39]. The WPAI-SHP measures overall impair-ment in activities (from work time missed, impairmentwhile working, and activity impairment outside of work)due to a health problem, expressed as percent impairment,which can be used to calculate associated cost. Statisticallysignificant improvement in both the WIS and the WPAI-SHP were observed in our pilot study.The second primary outcome will be time to work ces-sation, measured over 5 years of follow up. Work cessationis defined as complete cessation of work for more than6 months, the standard duration used by insurance com-panies to define permanent WD, and also consistent withdefinitions of WD in the employment literature [40]. Thisdefinition will capture WD from all health reasons (i.e. notonly related to arthritis), including early retirement, workcessation for personal reasons, and prolonged unemploy-ment periods when people are looking for another job, butwill not capture temporary WD, sick leave, or short pe-riods of unemployment of less than 6 months duration.veloped and validated based on a combination of thesize of 420 subjects (210 per group) completing the studyCarruthers et al. BMC Medical Informatics and Decision Making 2014, 14:59 Page 4 of 7 necessary for 80% power, a 2-tailed Cox model-basedscore test, equivalent to the logrank test, at alpha = 0.05,to detect a 35% relative risk reduction (HR = 0.65) in theintervention vs. control group, which was considered aminimally clinically important difference (MCID), and ismoderately conservative compared to the 42% risk reduc-tion observed in Allaire’s study (HR = 0.58, 95% CI:0.34-0.99) [34]. Assuming 20% loss to follow-up, we will recruita total of 526 subjects (263 per group). This sample willWorkplace Activity Limitations Scale (WALS) and WorkLimitations Questionnaire (WLQ); 5) Quality adjustedlife year (QALY), will be measured using EQ-5D andSF-6D, 2 years post intervention, for the cost-utilityanalysis; 6) Changes from baseline in job satisfaction,self-efficacy at work, work-related risk factors for WD(job physical demand, job autonomy, difficulty commut-ing, self-employment and support from co-workers, em-ployers and family), job accommodations, and job typewill also be evaluated, as exploratory analyses, in an at-tempt to understand the effect of the intervention onmediators of work disability.Sample size and analysisSample size was calculated for the primary outcome re-quiring the largest sample, i.e. time to work cessation. Itwas performed with PASS software [42] for time-to-event analyses. We assumed 5 years of follow-up and arate of work cessation of 12.77% per year in the controlgroup, based on the 40% work loss observed in controlsover 4 years in Allaire’s RCT of VRC [34], and assumingan exponential distribution of time to work loss. A sampleWhether or not work cessation should be restricted toarthritis related work cessation is an issue of debate in thearthritis employment literature. Because of difficulties at-tributing work cessation to a single cause (i.e. the decisionis often multifactorial and arthritis may have played somerole in the decision), it is generally recommended that all-cause work cessation be measured in studies including acontrol group [41].Secondary work outcomesSecondary work outcomes will include: 1) temporarywork cessation for any reason (i.e. sick leave, temporaryWD, and short periods of unemployment lasting morethan 2 months but less than 6 months); 2) occasionalwork absence (i.e. number of days missed from work peryear); 3) reduction in usual amount of time worked (i.e.reduction in hours per week worked); 4) At-work prod-uctivity measured using a new scale currently being de-ensure adequate power for our other primary outcome, at-work productivity.Appropriate descriptive statistics will be used to meas-ure baseline characteristics of the two groups. Analysisof treatment effectiveness will rely on intention-to-treat(ITT) approach, so that all patients initially randomizedwill be included in the analysis, regardless of their com-pliance or drop-outs.For the analysis of our first primary outcome, at-workproductivity measured as a continuous variable will betested for normality using the Shapiro-Wilk test [43]. Ifnormality assumption is rejected, an appropriate trans-formation (e.g. such as logarithmic) will be employed toobtain an approximately normal distribution. Next, anAnalysis of Variance (ANOVA) will evaluate the effect ofthe intervention on WIS measures at 2 years, adjustingfor the 12 strata and blocking. We will also consider anAnalysis of Covariance model after inspection of thebaseline values in both treatment arms for factors suchas WIS score, duration of disease, physician providingRA care, age, gender and risk factors for WD. If differ-ences at baseline are observed, we will consider them ascovariates. Since the power of these analyses will likelybe less than the original ANOVA, post hoc power ana-lyses will be conducted if these appear to be clinicallymeaningful adjustments.In the analysis of our second primary outcome, time-to-event (survival) methodology will compare the risk ofwork cessation in the intervention and control groups.Subjects employed until end of their follow-up (studyend, death or time of loss to follow-up, whichever occursearlier) will be censored. First, Kaplan Meier ‘survivalcurves’ and logrank test will estimate and compare theproportions of subjects who continue being employed inthe intervention and control groups. Next, multivariableCox Proportional Hazards (PH) regression model [44]will be employed to estimate the adjusted Hazard Ratio(HR) with 95% CI, associated with the intervention aftercontrolling for potential risk factors for WD that may beimbalanced at baseline, despite randomization, and forother important predictors, such as age, gender, RA dur-ation at baseline, and physician providing RA care, whoseomission could induce bias toward the null in time-to-event analyses [45]. We will use a flexible extension of theCox model [46], which will allow us to estimate how theHR reduction due to intervention changes over time, ifthe proportional hazard assumption (that the interventioneffect remains constant over time) is rejected.For analyses of secondary outcomes, time-to-eventmethods will be employed for dichotomous outcome vari-ables (e.g. time to temporary work cessation), and com-parison of means between intervention and controlgroups will be employed for continuous variables (e.g.measures of absenteeism, job satisfaction, self-efficacyand risk factors for WD), as described above for theprimary outcomes.Carruthers et al. BMC Medical Informatics and Decision Making 2014, 14:59 Page 5 of 7 the second primary outcome (time to work cessa-tion), an interim analysis will be performed at 2 years offollow-up. We will use the same method as for the pri-mary analysis and will employ the PETO criteria to adjustthe overall type I error for multiple testing [47]. Specific-ally, we will use a conservative type I error of 0.001 for theinterim analysis, which will allow us to maximize thepower of the final analyses of the 5 year outcomes, whichwill employ the conventional 0.05 significance level.We will also examine the incremental costs and benefitsof receiving the intervention versus standard of care. Botha cost-effectiveness analysis and a cost-utility analysis willbe performed. The outcome of our analysis will be the in-cremental cost-effectiveness ratio (ICER), which is the dif-ference between the mean costs of providing competinginterventions divided by the difference in effectiveness.Based on the primary outcome of the RCT, we will deter-mine the incremental cost of the intervention per workcessation avoided relative to standard treatment. Becausecost-effectiveness analyses are not robust to quantity orquality of life, we will also conduct a cost-utility analysis,where the primary outcome is the quality adjusted life year(QALY). Using health utilities measured by the EQ-5D andSF-6D, we will conduct a cost-utility analysis in which theincremental cost of the intervention relative to standardtherapy per QALY gained will be determined. Importantaspects of economic evaluations conducted alongside anRCT are excluding protocol driven costs, and dealing withmissing data due to attrition. We will follow recommenda-tions by the International Society for Pharmacoeconomicsand Outcomes Research for missing cost and effectivenessdata. We will use a combination of imputation and boot-strapping to quantify uncertainty due to missing valuesand finite study sample size. We will use propensity scores,stratified by treatment group, for imputing missing costsand effectiveness data due to attrition.LimitationsLimitations are those inherent to the study design andintervention. Participating in research, especially complet-ing questionnaires may trigger awareness of problems,leading to more active coping behaviour than “usual” inthe control group. The un-blinded nature of our interven-tion increases the risk of contamination (administration ofpart of the intervention to the control group, especially re-ferral to OT and VRC) and unequal co-intervention (i.e.unequal administration of additional measures to dealwith employment problems). However, these issues wouldreduce our ability to observe a difference between inter-vention and control group and therefore would constitutea conservative bias. Also, our recruitment strategy (i.e.avoiding prospective enrolment of consecutive patientsas they are seen by rheumatologists) was specificallydesigned to limit these risks. We will collect data todocument the extent to which contamination or co-intervention occurs.Our intervention is a complex one involving severalcomponents. Our study was designed to evaluate the ef-fectiveness of the intervention as a whole and not toevaluate the relative effectiveness of each component.Five years of follow-up is long and increases the risk ofloss to follow-up. However, this is the time required toevaluate work cessation. The importance of this out-come, in terms of quality of life and economic impact, atthe personal and societal level, warrants the difficulty ofa lengthy trial. Preventing work disability is the outcomemost relevant to health policy planners, employers, in-surance companies, and will influence the decision tofund the program as part of the multidisciplinary ser-vices offered to people with arthritis. We have designedstrategies to enhance retention.DiscussionWe have created a novel program for people with IA toimprove an aspect of disease management too often ig-nored by health professionals, the management of employ-ment issues. Our program is unique in that it combinesthe benefit of group sessions focused on improving self-management, with assessments by health professionalsspecifically addressing employment. The web-based tech-nology for delivering our program is at the leading edge oftrends in the field of adult education and self-managementprograms, and offers a number of advantages for facilitat-ing both learning and program dissemination.Our research initiative is one of few worldwide to developand test the effectiveness of interventions specifically tar-geted at employment. Before our program can be imple-mented as part of routine care, it is important that itseffectiveness be rigorously evaluated. The knowledge gainedfrom this RCT will be useful for health care professionalsto refer to the program, for health care policy planners toagree to fund it as part of multidisciplinary arthritis ser-vices, and for arthritis stakeholders to endorse the program,promote it and help disseminate it widely. By preventingWD, our program has the potential for great cost savings tosociety and huge personal impact on people’s lives.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionDL, as the principal investigator, conceived the study design and developed thestudy protocol. All co-investigators (CB, CHG, MG, CM, JV, LCL, JME) contributedto the study design and protocol. EC contributed to implementation of the RCTand manuscript writing. PR contributed to study design and implementation ofthe RCT. All authors read and approved the final manuscript.AcknowledgementsDiane Lacaille holds the Mary Pack Chair in Arthritis Research from TheArthritis Society of Canada and the University of British Columbia. Charles HGoldsmith holds the Milan and Maureen Ilich/Merck Chair in Statistics forArthritis and Musculoskeletal Diseases from the Arthritis Research Centre of8 years from onset. J Rheum 1998, 25:44– job retention and based on an empowerment perspective. Int ArchCarruthers et al. BMC Medical Informatics and Decision Making 2014, 14:59 Page 6 of 7 Environ Health 2006, 80:87–97.10. Lacaille D, White MA, Backman CL, Gignac MAM: Problems faced at workdue to inflammatory arthritis: new insights gained from understandingpatients’ perspectives. Arthritis Rheum 2007, 57:1269–1279.11. Nilsson I, Fitinghoff H, Lilja M: Continuing to work after the onset ofrheumatoid arthritis. Work 2007, 28:335–342.12. Mancuso CA, Paget SA, Charlson ME: Adaptations made by rheumatoidarthritis patients to continue working: a pilot study of workplacechallenges and successful adaptations. Arthritis Care Res 2000, 13:89–99.2. Eberhardt K, Larsson BM, Nived K: Early rheumatoid arthritis: some social,economic and psychological aspects. Scand J Rheum 1993, 22:119–123.3. Badley EM, Rasooly I, Webster GK: Relative importance of musculoskeletaldisorders as a cause of chronic health problems, disability and healthcare utilization: findings from the 1990 Ontario Health Survey. J Rheum1994, 21(3):505–514.4. Felts W, Yelin E: The economic impact of the rheumatic diseases in theUnited States. J Rheumatol 1989, 16(7):867–884.5. Escorpizo R, Bombardier C, Boonen A, Hazes JM, Lacaille D, Strand V,Beaton D: Worker productivity outcome measures in arthritis. J Rheum2007, 34:1372–1380.6. Vliet Vlieland TPM, De Buck PD, van den Hout WB: Vocational rehabilitationprograms for individuals with chronic arthritis. Curr Opin Rheum 2009,21:183–188.7. Mahalik J, Shigaki CL, Baldwin D, Johnstone B: A review of employabilityand worksite interventions for persons with rheumatoid arthritis andosteoarthritis. Work 2006, 26:303–311.8. De Buck PD, Schoones JW, Allarie SH, Vliet Vlieland TP: Vocationalrehabilitation in patients with chronic rheumatic diseases: a systematicliterature review. Semin Arthritis Rheum 2002, 32:196–203.9. Varekamp I, Verbeek JHAM, Van Dijk FJH: How can we help employeeswith chronic diseases to stay at work? a review of interventions aimedCanada and Simon Fraser University. Linda C Li holds the Harold Robinson/The Arthritis Society Chair in Arthritic Diseases from the University ofBritish Columbia.This research was funded by an operating grant from the Canadian Institutesof Health Research (F11-01115). The funding agency had no influence onstudy design, protocol development or the decision to submit themanuscript for publication, other than through the grant peer-review processwhich provided a review of the protocol.FundingThis research was funded by the Canadian Institutes of Health Research(F11-01115).Author details1Arthritis Research Centre of Canada, 5591 No. 3 Rd, Richmond, BC V6X 2C7,Canada. 2Department of Occupational Science and Occupational Therapy,University of British Columbia, T325-2211 Wesbrook Mall, Vancouver, BC V6T2B5, Canada. 3Faculty of Health Sciences, Simon Fraser University, 8888University Drive, Burnaby, BC V5A 1S6, Canada. 4Dalla Lana School of PublicHealth, University of Toronto, 10 MP-328, 399 Bathurst St, Toronto, ON M5T2S8, Canada. 5School of Pharmacy, Memorial University, Health SciencesCentre, 300 Prince Philip Drive, St. John’s, NL A1B 3 V6, Canada. 6School ofPopulation and Public Health, University of British Columbia, 2206 East Mall,Vancouver, BC V6T 1Z3, Canada. 7Department of Physical Therapy, Universityof British Columbia, 5591 No. 3 Rd, Richmond, BC V6X 2C7, Canada. 8Divisionof Rheumatology, University of British Columbia, 5591 No. 3 Rd, Richmond,BC V6X 2C7, Canada.Received: 2 June 2014 Accepted: 14 July 2014Published: 21 July 2014References1. 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Lancet 2005, 365(9471):1657–1661.doi:10.1186/1472-6947-14-59Cite this article as: Carruthers et al.: “Employment and arthritis: makingit work” a randomized controlled trial evaluating an online program tohelp people with inflammatory arthritis maintain employment (studyprotocol). BMC Medical Informatics and Decision Making 2014 14:59.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionCarruthers et al. BMC Medical Informatics and Decision Making 2014, 14:59 Page 7 of 7 your manuscript at


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