Effective outcomes management in occupational and environmental health

In the final analysis, outcomes management is about changing behavior, specifically in the occupational and environmental health practitioner's communication process and practice patterns and in the workers' prevention and compliance behavior. Outcomes management is also about quantifying results, establishing occupational and environmental health performance benchmarks, developing a best practices model and asking even more questions. As health care embraces the use of outcomes in evaluating its effectiveness, similar developments can be anticipated in occupational and environmental health. While occupational and environmental health outcomes management is still in its infancy, nurses in the workplace are well positioned to "shape it" into a useful tool that meets the needs of all the various practice settings. As nurses in the workplace begin to evaluate, report, and benchmark results, measurement tools will be refined, data bases will grow and new, useful benchmarks will be established. Because occupational and environmental health programs usually operate as part of a larger business unit, nurses in the workplace are continually faced with the challenge of ensuring that corporate programs including workers' compensation, health and disability benefit programs, vaccination programs, injury prevention, and health promotion or wellness programs are delivered in an efficient and cost-effective manner and that the expected outcomes are achieved. Effective outcomes management programs are the vehicles to effective goal achievement.     

Occupational injuries among working adolescents in New York State

OBJECTIVE: To determine the number, distribution, determinants, and health consequences of occupational injuries among working adolescents in New York State. DESIGN: A retrospective, population-based analysis of New York State workers' compensation award data and the Annual Demographic File, a supplement to the US Bureau of the Census Current Population Survey. PARTICIPANTS: Adolescents, aged 14 through 17 years, who received workers' compensation awards for occupational injury from 1980 through 1987. MAIN OUTCOME MEASURES: (1) Numbers, types, and rates of occupational injuries in working adolescents by age, sex, industry, and occupation; (2) health consequences of injury, especially disability and death; and (3) secular trends in injury award rates. RESULTS: A total of 9656 adolescents were compensated for occupational injuries; 4201 compensated adolescents (43.5%) suffered permanent disability; 31 working adolescents died. The annual mean rate of compensated occupational injury was 28.2 per 10,000 adolescent workers. Rates were higher in males than in females and ranged from 8.2 per 10,000 in 14-year-old male workers to 46.8 per 10,000 in 17-year-old male workers. Highest rates by industry were seen in manufacturing (49.0/10,000 adolescent workers) and agriculture (46.2/10,000). Unskilled labor was the most dangerous occupation (52.3/10,000). CONCLUSION: Occupational injuries are a substantial and underrecognized contributor to the continuing epidemic of injury among adolescents.     

Current methods of estimating severity for occupational injuries and illnesses: data from the 1986 Michigan Comprehensive Compensable Injury and Illness Database

National and state estimates of the severity of occupational injuries and illnesses (severity = lost work time = missed work days+restricted work days) have come from the annual Survey of Occupational Injuries and Illnesses (Survey) produced by the U.S. Bureau of Labor Statistics. However, we show that the Survey practice of collecting injury information soon after the accident year reduces substantially the accuracy of missed work day estimates, which constitute 85.3% of the Survey lost work time estimate. To develop an independent estimate of missed work days, the research team created the Michigan Comprehensive Compensable Occupational Injury Database (Michigan Database) by linking state files with injury characteristics to files with workers' compensation information for injuries occurring in 1986. The measure of missed work time (days, weeks, or years) is the cumulative duration of compensation from the "date disability commenced," noted on the first payment form, through follow-up to March 1, 1990. Cumulative missed work time has been calculated or estimated for 72,057 injured workers, more than 97% of the 73,609 Michigan workers with compensable occupational injuries in 1986 identified through the close of the study. Our "best" estimate of missed work days, to follow-up, attributable to both fatal and nonfatal compensable occupational injuries and illnesses is 7,518,784, a figure four times that reported for Michigan by the Survey. When insurance industry data on disbursements are also considered, the estimate of missed work days increases to 8,919,079, a figure 4.75 times that reported by the Survey. When insurance data on reserves for future payments are also considered, the estimate of missed work days increases to 16,103,398, a figure 8.58-fold greater than that obtained for Michigan in the Survey. The Michigan data suggest that the national Survey may have failed to identify almost 373 million of 421 million missed work days in the private sector that have resulted, or will result, from 1986 occupational injuries. The present federal/state system for estimating occupational injury severity by measuring lost work days seriously underestimates the magnitude of the problem. The current policy of obtaining incidence and severity data from the same Survey should be reconsidered. We recommend that national estimates of injury severity be obtained from representative states by using state compensation data and that such estimates be used to evaluate current prevention and rehabilitation strategies. The redesigned occupational safety and health Survey (ROSH Survey) should be revised to permit linkage to compensation data.     

Main trends n solving problems of preventive medicine in gas industry of the Far North

A three-stage system for workers' health care was created in Nadymgazprom enterprises. Made over recent 3 years, improvement of medical service for Nadymgazprom stuffers has resulted in better health state of the workers including shifted ones, in significantly lower morbidity with transitory disablement and in reduced disability rate.     

Should extended disability be an exclusion criterion for tertiary rehabilitation? Socioeconomic outcomes of early versus late functional restoration in compensation spinal disorders

STUDY DESIGN: A prospective cohort design with two groups of patients representing short-term or long-term disability (n = 497) who were selected from a larger cohort (n = 938) of consecutively treated spinal disorder patients with chronic compensation injuries. OBJECTIVES: To prospectively evaluate the impact of length of spinal disability on socioeconomic outcomes of medically directed rehabilitation. SUMMARY OF BACKGROUND DATA: Despite an increasing tendency of managed care organizations to limit rehabilitation services for disabled workers with chronic spinal disorders, there has been a surprising lack of prospective research evaluating the impact of length of disability on objective socioeconomic treatment outcomes. Although only approximately 10% of all patients with spinal disorders are disabled beyond 4 months, they account for nearly 80% of all workers' compensation expenditures. Little is known about whether relatively early intervention improves outcomes after chronicity has been established or whether any predictors distinguish between these groups. METHODS: Two comparison groups of functional restoration tertiary treatment graduates were identified from the same community referral pool. The "long-term disabled" group involved a minimum of 18 months of disability (n = 252). This group was compared with a "short-term disabled" group (n = 245), no more than 8 months since injury, but chronic based on a minimum of 4 months after injury. The long-term disabled group showed significantly higher rates of pretreatment surgery than the short-term disabled group (P < 0.001). All patients were evaluated prospectively with specific physical, psychological, and occupational measurements. They also underwent a structured interview 1 year after treatment evaluating work status, health care use, and recurrent injury. RESULTS: The short-term disabled group showed statistically higher return to work (P < 0.001) and work retention (P < 0.05) relative to the long-term disabled group. However, health care use and recurrent lost time injury claims were low in both groups and did not differ significantly. No predictors of outcome were found among the prospectively collected physical performance or psychosocial variables. CONCLUSIONS: This study suggests that early tertiary nonoperative care, once patients with chronic spinal disorders are identified as having potentially high-cost chronic pain and disability, is efficacious in achieving goals of better work return and work retention. Such early rehabilitation may also prevent significant indemnity expense, as well as some late surgical interventions sought by progressively more desperate patients. However, individuals with long-term disability achieve respectable work return and retention rates, while faring no worse on other socioeconomic outcomes that represent major "cost drivers" to the workers' compensation system. Early intervention is not a panacea or a necessary condition for the successful rehabilitation of workers with disabling chronic spinal disorders.     

Differential efficiency of expression of humanized antibodies in transient transfected mammalian cells

BACKGROUND: Wide variations in disability duration and magnitude have been noted among recipients of workers' compensation for low back pain. Findings from recent studies have indicated that inclusion of a broad array of variables (i.e., physical, occupation, social, economic) is needed to understand differences in workers' responses to occupational low back pain. METHODS: Workers' compensation and questionnaire data from 340 Oregon workers with low back claims were merged to develop multivariate models predicting: (1) absenteeism days, (2) residual symptoms, (3) functional impairment, and (4) medical costs. RESULTS: Forty-two percent of the variation in low back symptoms was explained by: discontinuing physical fitness activities post-injury (beta = -.419), self-reported low energy/high fatigue (beta = -.227), poorer general health (beta = .137), and attorney involvement in claim (beta = .117), (adjusted R2 = .418, p < 0.001). Survival curves revealed significantly longer claim durations among workers who discontinued physical fitness activities post-injury, compared with workers who did not; these differences remained significant even after controlling for severity of the initial injury. CONCLUSION: Continuation of physical fitness activities during the recovery process was found to be a significant predictor in three of four regression models, providing evidence on behalf of a relationship between fitness and positive health outcomes. However, it was not possible to clearly differentiate pre-morbid from post-injury fitness, nor to determine if this relationship was due to a therapeutic effect on the back, the general restorative benefits of remaining active, or represents a proxy variable for workers' self-care efforts during recovery.     

Uses of workers' compensation data in epidemiology research

Contrary to general opinion, workers' compensation data can be helpful in epidemiologic research. Dr. Goldsmith assesses several studies based on data culled from workers' compensation or disability programs and explains how valuable information was derived.     

Role of psychologists in Canadian pain centres.

Interviewed 9 Canadian psychologists in pain-treatment settings concerning their professional roles and the training that prepared them for these roles. Ss were young and had been involved in pain centers for a relatively short time, but they represented a wide variety of settings, from hospitals and rehabilitation centers to workers' compensation boards and private practice. Similarly, functions in those settings varied considerably, from psychologists who play a relatively minor, consulting role, to those in charge of administration and treatment in their centers. Across settings, however, there was considerable consensus concerning approaches to assessment and treatment and concerning the appropriate background to prepare psychologists to practice in pain centers. Most Ss recognized that complete elimination of pain is not possible for most people with chronic pain. Therapy can, however, result in improvements in mood, level of physical activity, vocational productivity, and social adjustment, as well as reductions in reported pain, use of medications, and unnecessary visits to physicians. Although the growth of pain-related positions for psychologists is not rapid, there appears to be an increasing number of such jobs available. (French abstract) (30 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Suggested guidelines for rating cardiac disability in workers' compensation. Medical and Chiropractic Advisory Committee to the Administrative Director of the California Division of Industrial Accidents

Cardiac disability ratings in workers' compensation cases currently lack any consistent scientific basis, with varying medical evidence used by different examiners in the same case. Opinions about the extent of disability may differ with the same patient, delaying resolution and the delivery of benefits. We describe guidelines for determining cardiac impairment and suggest a schedule for rating disability based on evidence. Our experience is in California, but arriving at equitable ratings for disability purposes is a nationwide challenge. Exercise stress testing provides the best reproducible data to test the heart's ability to do work. When exercise stress testing is not possible or adequate, alternative or supplemental testing is necessary. Certain conditions, such as hypertension, arrhythmias, coronary artery spasm, and a history of coronary artery operations or myocardial infarction, may affect "cardiac disability" but may not necessarily be reflected in exercise testing.     

Trends in disability duration and cost of workers' compensation low back pain claims (1988-1996)

Previously published epidemiologic studies of low back pain (LBP) have reported that the prevalence of low back disability has increased dramatically. These studies based their findings on either the number of disability claims filed, the disability duration, or both. This information was from countries other than the United States or from the US Social Security Disability Insurance data, with findings reported only to the early 1980s. More recent studies of US workers' compensation LBP claims reported a decrease in the incidence rate from the late 1980s to the mid-1990s. No studies have been found that report on the trends of disability duration for workers' compensation LBP claims. This study examined recent trends in the length of disability (LOD) for LBP claims and associated costs, using a large sample of claims from the privately insured US workers' compensation market. LOD and cost information were derived for injuries from 1988, 1990, 1992, 1994, and 1996. For each year, the distributions of LOD and cost were skewed, with the small percentage of claims that lasted more than one year (4.6%-8.8%, depending on the year) accounting for a large percentage of the total disability days (77.6%-90.1%) and cost (64.9%-84.7%). From 1988 to 1996, the average LOD decreased 60.9%, from 156 days to 61 days. The probability of being on disability for a long period of time has decreased over the years. Over the study period, the average cost of a claim decreased 41.4%, while the median cost increased 19.7%. The most influential change in the LOD and cost distributions was a reduction in expensive claims with a long disability duration. The evolution of LOD and cost is also detailed for different disability durations for the study period.     

Perception of traumatic onset, compensation status, and physical findings: impact on pain severity, emotional distress, and disability in chronic pain patients

The primary purposes of the present study were to investigate the roles of physical findings, financial compensation, and types of pain onset (i.e., trauma vs. insidious onset) on adaptation by chronic pain patients. Comparisons between patients who were receiving or seeking compensation and those who were not revealed that, despite comparable degrees of physical findings, the compensation status was associated with reports of (a) more severe pain, (b) greater disability, (c) higher levels of emotional distress, and (d) greater life interference. The compensation status of 74% of the patients was correctly classified by combination of pain severity, perceived disability, and life interference. Objective indices of physical findings did not significantly improve classification accuracy. In order to eliminate the possible confound of compensation, analyses of the relationship between the types of onset and chronic pain were conducted only for a subset of patients who were not receiving or actively seeking compensation. The results indicated that the patients who attributed their pain to a specific trauma reported significantly higher levels of emotional distress, life interference, and higher levels of pain severity than did the patients who indicated that their pain had an insidious or spontaneous onset, regardless of the extent of objective physical findings.     

The Americans with Disabilities Act and injured workers: Implications for rehabilitation professionals and the workers' compensation system.

Examines theoretical and practical interactions between the Americans with Disabilities Act of 1990 (ADA) and the workers' compensation system. The ADA changes the workplace and assists the rehabilitation psychologist to intervene in the process that turns impairments into disabilities. The practical focus of employers must change from paying workers off to keep them from the workplace to aggressively trying to return them to work. Injured workers can be an "individual with a disability" under the ADA and qualified, with or without reasonable accommodation, to perform a job's essential functions if they are permanently disabled for workers' compensation purposes. The ADA's benefits and pitfalls for the rehabilitation psychologist and other rehabilitation professionals are outlined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Occupational pathology: present and future

Formed 75 years ago, occupational pathology has defined structure of occupational morbidity, determined principles of occupational diseases' pathogenesis and pathomorphosis, demonstrated dependence of occupational entities on acting occupational hazards, described clinical manifestations of occupational diseases, emphasized informative diagnostic complexes. Diagnosis in occupational pathology now is established on basis of etiology. Manifold activities helped to form a system preventing health disorders caused by occupational hazards. Topical problem is to elaborate and put into practice some criteria for compensation of occupational damage with differential expert assessment of functional disorders caused either by occupational disease or by general one. Prospective trend could be to create a system organizing and managing workers' health on workplace and to put "protection by time" principle into practice with forecasting risk of occupational diseases and dose-effect dependence. Another prospect is to elaborate and put into practice a training in social and psychologic adaptation for occupational managers and industrial workers.     

Clinical overview of occupational lung disease

The workplace has been a source of lung injury for centuries, yet awareness of the types of injuries has varied over time. Because of distinctive differences among the occupational lung disorders, a continual update of the clinical findings, dose response data, physiologic characteristics, and radiographic findings is needed. The radiologist plays a key role for the evaluation of miners, foundry or factory workers exposed to mineral dusts, and of workers exposed to the "biologic" dusts, infectious agents, cancer causing agents, and chemicals causing interstitial lung diseases. This overview includes a discussion of classification systems, criteria for diagnosis of occupational lung diseases, the pulmonary clinician's evaluation, and important aspects of specific disorders and concludes with a discussion of pulmonary disability determination.     

Heparin, but not other proteoglycans potentiates the mitogenic effects of FGF-2 on mesencephalic precursor cells

Occupational asthma may account for a significant proportion of adult-onset asthma, but incidence estimates from surveillance of physician reports and workers' compensation data (0.9 to 15/100,000) are lower than expected from community-based cross-sectional studies of asthma patients. We conducted a prospective cohort study of 79,204 health maintenance organization members between the ages of 15 and 55 at risk for asthma. Computerized files, medical records, and telephone interviews were used to identify and characterize asthma cases. Evidence for asthma attributable to occupational exposure was determined from work-related symptoms and workplace exposure. The annual incidence of clinically significant, new-onset asthma was 1.3/1,000, and increased to 3.7/1,000 when cases with reactivation of previously quiescent asthma were included. Criteria for onset of clinically significant asthma attributable to occupational exposure were met by 21% (95% CI 12-32%) of cases giving an incidence of 71/100,000 (95% CI 43-111). Physicians documented asking about work-related symptoms in 15% of charts, and recorded suggestive symptoms in three cases, but did not obtain occupational medicine consultation, diagnose occupational asthma, report to the state surveillance program, or bill workers' compensation for any of them. These data suggest that the incidence of asthma attributable to occupational exposures is significantly higher than previously reported, and accounts for a sizable proportion of adult-onset asthma.     

Disability and cognitive impairment in the elderly

Disability and cognitive impairment show similar patterns of increasing frequency with ageing. A review of the published literature shows that there is a cross-sectional relationship between cognitive impairment and disability, independent of demographic, medical, and lifestyle factors. Some instrumental activities of daily living (IADL) items appear more specifically related to cognitive impairment, but cognition and functional impairment are distinct concepts requiring separate assessments. Subjects with low cognitive performances are at higher risk of functional impairment in the following years. Cognitive impairment as well as disability increase the risk of death and institutionalization. Preventive strategies could be directed against the risk factors of cognitive impairment and disability, and would aim to delay the onset of dementia. Prevention of disability associated with cognitive impairment needs further assessment in elderly community-dwellers. Further research is needed to better identify the specific areas cognition involved in the disablement process.     

Differences in receipt of rehabilitation by impaired midlife men and women.

This analysis used data from the 1978 Survey of Disability and Work to assess gender differences in the receipt of rehabilitation services. The findings point to a continuing puzzle: Approximately equal proportions of impaired men and women received rehabilitation services; yet even when age, work history, severity of impairment, and receipt of disability insurance or workers' compensation were controlled for, a larger proportion of men than women were in the labor force after rehabilitation. Men were more likely than women to receive employment-related rehabilitation services. Furthermore, prediction of the receipt of rehabilitation services was poorer for women than for men. Variables hypothesized to predict receipt of rehabilitation were significant predictors for men, but not for women (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neurology and psychiatry

This study examined 4,547 workers' compensation claims accepted for hearing-related conditions in Washington state between 1984 and 1991; 80% resulted in disability compensation (n = 3,660). Acute hearing-related conditions comprised 11% of accepted conditions (95% confidence interval [CI], 2-15%); most claims were for chronic noise-related hearing loss. Tinnitus was reported in 64% of accepted claims (95% CI, 54-75%). The median binaural-equivalent hearing loss in compensated claims was 12.5% (inter-quartile interval, 5-22%; 90th percentile, 34%), although it declined by 30% during the study period. The number of claims and associated impairment increased with claimant age, but the number of claims dropped dramatically after age 65. Annual total disability settlements almost tripled in 8 years, totaling $22.8 million. This study indicates that occupational hearing-related conditions: 1) are manifested by mild to moderate hearing loss, accompanied by tinnitus in a majority of cases; 2) may be under-recognized in older, formerly noise-exposed individuals; and 3) were associated with substantial increases in compensation and medical costs over time, through 1991.     

The enigma of "hidden" traumatic brain injury

OBJECTIVE: To examine individuals with "hidden" traumatic brain injury (TBI), defined in this study as those who sustained a blow to the head, with altered mental status, and experienced a substantial number of the cognitive, behavioral, and emotional sequelae typically associated with brain injury but did not make the causal connection between the injury and its consequences. DESIGN: Comparison of four groups of individuals matched for age, gender, years of education, and duration of loss of consciousness. SETTING: This study of hidden TBI followed the identification of 143 individuals who, within a larger study of people with TBI who live in the community, identified themselves as "nondisabled" (they were to be part of the comparison sample) but who had experienced a blow to the head that left them at minimum dazed and confused. PARTICIPANTS: 21 of these 143 individuals also reported large numbers of symptoms (eg, headaches, memory problems) associated with TBI. This group (Hidden TBI-High Symptoms group) was compared to three other matched samples: one with known TBI (Known Mild TBI group) and one with no disability (No Disability group) (both of which were drawn from the larger study), and one group of individuals who identified themselves as having no disability but who had experienced a blow to the head that resulted in a few symptoms (Head Trauma-Low Symptoms group). MAIN OUTCOME MEASURES: All study participants were administered an interview that incorporated several existing instruments documenting levels of reported symptoms, emotional well-being/distress, and vocational/social handicaps. RESULTS: The Hidden TBI-High Symptoms group was found to be similar to the Known Mild TBI group in terms of the number and types of symptoms experienced, whereas the Head Trauma-Low Symptoms group was similar in this respect to the No Disability group. The two former groups also evidenced high levels of emotional distress, whereas the two latter groups did not. However, on measures of handicap, the Hidden TBI-High Symptoms and Head Trauma-Low Symptoms groups were similar to the No Disability group and dissimilar from the Known Mild TBI group in that the last group experienced vocational handicap, in particular, whereas the other groups did not. Conclusions: We conclude that hidden TBI occurs at a nontrivial level (7% of our nondisabled sample). Also, individuals with hidden TBI (with persistent symptoms), unlike those with known mild TBI, are likely to experience emotional distress but not vocational handicap following injury.