title: Pre-employment examinations for preventing injury, disease and sick leave in workers.
abstract: BACKGROUND
  Many employers and other stakeholders believe that health examinations of job applicants prevent occupational diseases and sickness absence. This is an update of the original Cochrane review (Mahmud 2010).
  
  
  OBJECTIVE
  To evaluate the effectiveness of pre-employment examinations of job applicants in preventing occupational injury, disease and sick leave compared to no intervention or alternative interventions.
  
  
  METHODS
  We searched CENTRAL (the Cochrane Library), MEDLINE, EMBASE, CINAHL, PsycINFO and PEDro (up to 31 March 2015). We did not impose any restrictions on date, language or publication type.
  
  
  METHODS
  We included randomised controlled trials (RCTs), controlled before-after (CBA) studies, and interrupted time-series (ITS) studies of health examinations to prevent occupational diseases and injuries in job applicants in comparison to no intervention or alternative interventions.
  
  
  METHODS
  All five review authors independently selected studies from the updated search for inclusion. We retrieved two new studies with the updated search from 1 April 2008 to 31 March 2015, resulting in a total of eleven studies.
  
  
  RESULTS
  We included two RCTs, seven CBA studies and two ITS studies. Nine studies with 7820 participants evaluated the screening process of pre-employment examinations as a whole, and two studies with 2164 participants evaluated the measures to mitigate the risks found following the screening process. The studies were too heterogeneous for statistical pooling of results. We rated the quality of the evidence for all outcomes as very low quality. The two new CBA studies both used historical controls and both had a high risk of bias.Of those studies that evaluated the screening process, there is very low quality evidence based on one RCT that a general examination for light duty work may not reduce the risk for sick leave (mean difference (MD) -0.09, 95% confidence interval (CI) -0.47 to 0.29). For army recruits, there is very low quality evidence based on one CBA study that there is a positive effect on fitness for duty after 12 months follow-up (odds ratio (OR) 0.40, 95% CI 0.19 to 0.85).We found inconsistent evidence of an effect of job-focused pre-employment examinations on the risk of musculoskeletal injuries in comparison with general or no pre-employment examination based on one RCT with high risk of bias, and four CBA studies. There is very low quality evidence based on one ITS study that incorporation of a bronchial challenge test may decrease occupational asthma (trend change -2.6, 95% CI -3.6 to -1.5) compared to a general pre-employment examination with lung function tests.Pre-employment examinations may also result in a rejection of the applicant for the new job. In six studies, the rates of rejecting job applicants increased because of the studied examinations , on average, from 2% to 35%, but not in one study.There is very low quality evidence based on two CBA studies that risk mitigation among applicants considered not fit for work at the pre-employment examination may result in a similar risk of work-related musculoskeletal injury during follow-up compared to workers considered fit for work at the health examination.
  
  
  CONCLUSIONS
  There is very low quality evidence that a general examination for light duty work may not reduce the risk for sick leave, but may have a positive effect on fitness for duty for army recruits after 12 months follow-up.There is inconsistent evidence of an effect of job-focused pre-employment examinations on the risk of musculoskeletal injuries in comparison with general or no pre-employment examination. There is very low quality evidence that incorporation of a bronchial challenge test may decrease occupational asthma compared to a general pre-employment examination with lung function tests. Pre-employment examinations may result in an increase of rejecting job applicants in six out of seven studies. Risk mitigation based on the result of pre-employment examinations may be effective in reducing an increased risk for occupational injuries based on very low quality evidence. This evidence supports the current policy to restrict pre-employment examinations to only job-specific examinations. Better quality evaluation studies on pre-employment examinations are necessary, including the evaluation of the benefits of risk mitigation, given the effect on health and on the financial situation for those employees who do not pass the pre-employment examination.
authors.affiliation: Department of Public and Occupational Health, VU University Medical Center, EMGO+ Institute, Van der Boechorststraat 7 - room A524, Postbus 7057, Amsterdam, Netherlands, 1007 MB.
authors.forename: Frederieke G
authors.initials: FG
authors.lastname: Schaafsma
authors.forename: Norashikin
authors.initials: N
authors.lastname: Mahmud
authors.forename: Michiel F
authors.initials: MF
authors.lastname: Reneman
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Fassier
authors.forename: Franciscus H W
authors.initials: FH
authors.lastname: Jungbauer
mesh_terms: D000062:Accidents, Occupational / Q000517:prevention & control*; D065187:Controlled Before-After Studies; D004651:Employment; D006801:Humans; D065186:Interrupted Time Series Analysis; D009784:Occupational Diseases / Q000517:prevention & control*; D010560:Personnel Selection / Q000379:methods*; D010808:Physical Examination; D016032:Randomized Controlled Trials as Topic; D018582:Sick Leave / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000517:prevention & control*