Principles of management of occupational and environmental diseases: prevention, compensation, and return-to-work Chung-Li Donald Du, Center for Management.

Principles of management of occupational and

environmental diseases: prevention, compensation, and

return-to-workChung-Li Donald Du,

Center for Management of Occupational Injury and Diseases, National Taiwan University Hospital Jun

g-Der WangInstitute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public

Health

Outline Occupational health Occupational injury Occupational medicine as a specialty Occupational health care and management Notification or surveillance of occupational

injury and diseases From ad hoc system to prevention,

compensation, return to work (PCR) integration in Taiwan

PCR model and perspective

HealthWHO charter: Health is a state of

complete physical, mental and social well-being and not merely the absence of disease or infirmity

Occupational and environmental Occupational and environmental

factors in the health circlefactors in the health circle

NOTES: Adapted from Dahlgren and Whitehead, 1991. The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman, 1999).

Over the life span

Living and working conditions may include:

• Psychosocial factors• Employment status and occupational factors • Socioeconomic status (income, education, occupation)• The natural and builtc environments• Public health services• Health care services

Occupational Health Status

rapid proliferation of new industrial materials, new production methods, and new commercial products

little attention to the need and assessment of their impact for the human health and environment

The newly used chemicals developed by industries are even seldom tested for toxicity for animals or humans


practicing physicians take the burden of diagnosing, treating and if possible preventing work-related illness or injury

Even the medical and biological professionals are exposed to microbial agents, including bacteria, virus, fungi and parasites

Occupational infection could occur after contact with infected persons, with infected animal or human tissue, secretions, or excretions


“ergonomics” or human factor engineering has been introduced into the workplace

workers’ health problem arise from designs of workstations, tools, equipments or work procedures

physical agents such as noise or vibration, heat or cold, and ionizing or non-ionizing radiation

four steps of industrial hygiene -- anticipation, recognition, evaluation, and control of health hazards to reduce occupational hazard


work stress - increasingly important health problem; the ability to predict a stress response or make diagnosis of work stress related psychological and physiological disability is poor

the number of compensation claim of work related circulatory disease increased

workplace wellness and occupational health education program evolved

quit smoking, healthy diet, exercise, stress management and cardiovascular disease prevention

Occupational mortality - disease more than injury related to occupation

30 LWC

300 Recordable

30,000 Near Misses

300,000 At-Risk Behaviors

Fatality, Disabling Injury1

23% Circul.7% Respir.

32% Cancer

17%Comm.dis.

19% Accidents

1%

0%

1%

Communicable diseases CancerRespiratory Diseases Circulatory diseasesMental Disorders Digestive systems diseasesGenitourinary system Accidents and violence

Deaths attributed to workILO

Taiwan’s occupational disease underestimated

1990 1991 1992 1993 1994 1995 1996 1997

Taiwan 46 26 27 19 14 31 46 142

Singapore 940 1,070 897 900 999 1345 1,521 1,054

Korea 1,328 1,413 918 1,120 1,529 1,424

Hong Kong 244 93 248 272 369 327

Japan 11,415 11,951

10,842 9,630 9,915 9,230

Thailand --- --- 62 116 125 51

Malaysia 77 502 2,942

South Australia

2,995 2,841 2,824 3,145

Statistics of Asian occupational disease 1990-1997


In Taiwan there is still a underreporting of occupational disease, according to Bureau of Labor Insurance (BLI) statistics, if pneumoconiosis is excluded, the number of occupational disease is less than two hundred cases per year in recent two decades

which is around one in ten or one in a hundred of expected number, after comparison with neighboring countries, such as Japan, Korea Singapore, or USA

Occupational injury

Taiwanese workers suffered an estimated 36,000 fractures, amputations, lacerations, and hundreds of eye injury and burns out of occupational causes.

The most common occupational injuries involve musculoskeletal system or musculoskeletal diseases

strain, sprain, tendonitis, bursitis, myositis, arthritis - usually produced by repeated movement and muscle strain.

Gradual i ncrease of occupat i onali nj ury temporary di sabi l i ty cases

(1990~2002, BLI )

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

100000

110000

120000

130000

140000

150000

160000

170000

180000

190000

200000

210000

220000

230000

240000

250000

260000

270000

280000

290000

300000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002Year

Occupat i onali nj ur ies anddi seases

Actualpayment f ori nj ur ies anddi seases

NationalHealth

Insurance

Occupational Injury

According to BLI, the percentage of occupational injury with temporary disability is about one fourth of ordinary injuries among workers

trend of increased occupational injury and disease – esp., after National Health Insurance System enacted in 1995

incur more than 6 billion NT$ in direct workers compensation costs

indirect cost: production delays, damage to equipment, and recruiting and training replacement workers

estimated to be five times, or about 30 billion NT$

I ncreased percentage of occupat i onal i nj uryamong total i nj ury rel ated temporary

di sabi l i ty (1990 2002, BLI )～

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Year

Occupat i onali nj ur ies anddi seases

Actualpayment f ori nj ur ies anddi seases

Occupational Injury

Workers’ compensation benefits - permanent total disability, temporary total disability, permanent partial disability, temporary partial disability, and survivor’s benefits.

In Taiwan, only lump sum but no annuity paid to the insured worker.

During rehabilitation period, only sick leave or designated auxiliary tools for handicapped are offered

no vocational or psychological counseling or retraining or job placement assistance, compared to United States or most European countries

medical expenses of five main occupational injury after NHI

Meanwhile, Labor insurance compensation claim also increase dramatically !!

1996- 1999Cost due to hospi tal i zat i on

2.492.101.77

1.42

0.86 0.89 0.991.17

0.19 0.21 0.30

0.64

1.20

0.840.92 0.93

0.350.260.24 0.33

0

0.5

1

1.5

2

2.5

1996 1997 1998 1999Hundred

Million

Fracture

Open wounds of

upper extremity

Rolling over

Burn

Head trauma

Occupational Medicine specialty

AD 1700, Bernardino Ramazzini, the father of occupational medicine and an Italian physician: De Morbis Artificum Diatriba

to work without acquiring a wretched disease that would make one’s work a curse rather than a love

diseases of metal digger, painters, midwives, glassmakers, potters, sewer worker

affliction by inhaling noxious gases and dusts, or from disorderly motions and improper postures of the body


the primary care physician have taken the responsibility of health care for the industry

worker’s compensation issues usually followed after treatment

occupational compensation system emerged from Germany since mid-19 century

state (or government) run vs. private insurance carriers

most are compulsory, and even with penalties for not having insurance


The employer’s responsibility which includes providing medical treatment and compensation benefits transferred to the insurance agencies

preventing injury or disease shared by the employer and the insurers or related authorities

reporting of occupational injury - employer reporting of occupational illness -

physicians


occupational physician system accompanied the progress and change of industry

new legislation to protect the workers’ health and enhance their benefits

high-tech ages - labor force subjected to conditions never before confronted in the small shop or craftsman era

Production and profit are still the primary concern of company, not employee safety

practice of occupational medicine cover even a broader scope

Occupational Medicine specialty- to meet the demand of society

modern society occupational hazard - stress and related disease, musculoskeletal disorder

occupational physicians have to realize the regulatory or compensation system, able to design suitable occupational health program

To integrate occupational medicine with environmental, occupational safety and health

to serve for both the employer and employee to discover new techniques or strategies

Occupational health care & Management

Health care industry- cost containment, managed care system

Change is a requirement of life and an integral part of all complex endeavors of society, including the financing, provision and organization of health care service

Taiwan- National Health Insurance system, cover nearly all hospitals and clinics.


clinical managed care - to change the number or mix of services provided and to reduce the price paid for service

case management is a process, one component in the managed care strategy

the inclusion of salary replacement is not inherent to the health insurance managed care market

evaluation of quality of care, and timely return to work by injured employees more important in occupational health care

Definition of case management

”case management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes.”

major areas of activity - medical, financial, behavioral/motivational, vocational

the Commission for Case Manager Certification (CCMC)


In workers’ compensation, managed care must address a different objective-restoring a worker to health and productivity at the lowest cost.

New South Wales, Australia, the original Workers Compensation Act in1987 was later amended and renamed as “Workplace Injury Management and Workers Compensation Act” in 1998.


The act begins with notification of an injury by the employer, physician or patient

WorkCover New South Wales, make early contacts with all parties, assess the claim and performing medical examination at the request of employer or employee

The goal of injury management is to achieve optimum results in terms of the timely, safe and durable return to work for workers following workplace injury


All parties- the insurer, employer, injured worker and treating doctors, are required to cooperate and participate in the injury management process to ensure that optimum return to work results are achieved

This injury management code - the return to work program, the return to work coordinator, accredited rehabilitation provider, provision of suitable duties, keeping information confidential, and training and employment programs

Notification or surveillance of occupational injury and diseases

notification is a basic obligation in Australia as well as in Singapore and Germany, followed by the insurer or authorities to assist if the injured worker are eligible for compensation

Most occupational compensation system have an effective reporting system

no mandatory notification program in occupational compensation system in Taiwan would greatly cause the injured worker to be neglected, poorly rehabilitated, and at risk of job loss


Department of Health of Taiwan had launched a “work related disease notification system” since 1996, which encourage physicians, either from clinic, hospital or factory to be reporting resources

Until now, there are more than ten thousand cases reported. Most of them are injures, decompression sickness, hearing impairment and sharp injury

However, following management process is not linked to compensation or jurisdiction system in Council of Labor Affairs


In National Taiwan University Hospital, an in-hospital emergency room (ER) surveillance system was started since last Sep (2003)

ER : chemical injury, eye injury, occupational trauma, electrocutions and welder’s disease.

Taipei county government independent law in 2002 to punish those employer or practicing physicians within geographical boundary not to report occupational disease

In summary, the reporting of occupational injury or disease is still not “Notifiable”

From ad hoc system to prevention, compensation & RTW integration

WHO “ Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

occupational injuries and illness may cover social consequences including workers’ psychological and behavioral responses, vocational function and family and community relationship

5 Levels of public health principle : Health promotion -> special protection -> early diagnosis & treatment -> restriction of disability –> rehabilitation and return to work


most injured workers report that the primary treating physician did not give them any advice about the prevention of further injury

a large proportion (38%) of injured workers experience a reinjury after returning to work

many return to their jobs after a work injury continue to experience residual pain

Satisfaction with medical care provided through workers’ compensation generally lower than for general health care provided for non-occupational conditions

Dr. Pransky et al. AJIM, 2001

PCR case management model

PCR--- Prevention

Compensation

Rehabilitation (Return-to-work) Benefits as : reduction of injury with disability encouraging return to work save medical and insurance cost

Center for Management of Occupational Injury & Disease Joint collaboration among

Council of Labor Affairs (Bureau of Labor Insurance) and the hospital

Develop intra-and extra- mural surveillance system

Setup of standard diagnosis and case management model

Workability evaluation technique and occupational rehabilitation

~Since Apr,26,2003

Case Demand & Management

Occupational disease diagnosis

Treatment of injury and disease

Prevention of occupational injury

RTW demand

Compensation demand

Physical examinationJob evaluationMedical consultation Special exam.Factory walkthrough

DrugsP.TO.Tother

Health screenSafety advise & educationWork

hardeningnegotiation

CertificationFree charge of visitSupport resources

Seven ways of reactive prevention of occupational injury/disease

Health screening Surveillance Occupational disease dia

gnosis Disability evaluation Worksite visit Case management and c

ounseling Epidemiological study

Prevention by Health Screening Process to Factory workers

walkthrough exposure and HE items questionnaire

Qualified medical screening / assurance

Computerization of database

screening of possible exposure workers chronic illness factors evaluation data management (risk assessment） follow up and health promotion

Personal health evaluation Action： weight reduction、 quit smoking、 body fitness

疑似重金屬中毒、鉛中毒、砷中毒、錳中毒、黃磷中毒　汞中毒、鉻中毒、疑似氣體、蒸氣危害

疑似異常氣壓疾病　疑似農藥中毒疑似皮膚病疑似外傷疑似塵肺症疑似聽力損害疑似腕隧道症候群疑似針扎事件疑似肌肉骨骼傷害疑似職災死亡其他與環境或職業相關疾病

Electrical & Chemical burns Intoxication/pesticide Occupational asthma, T.B.,

allergic pneumonitis, dermatitis

Hand injury (cut, tear, compression)

Amputation/fracture Musculoskeletal disorder Young stroke, CVD HIVD, Peripheral

neuropathy Others

NTUH Surveillance

DOH, Taiwan

CMOID OPD statistics

OM OPD first visit

0

50

100

150

200

92-1Q

92-2Q

92-3Q

92-4Q

93-1Q

patient no.

distribution of first visit (92-4Q)

34%

28%

6%

24%

8% medical

jurisdiction

compensation

prevention

RTW

Cases Management: registration, compiling, advise, commu

nication & follow-up 15

1211

76

54 4

3 3 32 2 2 2

1 1 1

fascistic

PE

Pneumoconios

is

Needle

stick

chemical

Mental Stress

fracture

noise

jurisdiction

retinopa

thy

CTS

Amputati

on

HIVD

T.B

dermatitis

insomnia

Solvent expo.

RSI

4

8

12

16

Disability Evaluation & Return To Work flowchart

W.E need verified by Physician or OT

Refer for physical training

Job Hx.content analysis、 ADL、Pain、 FCE & other tests (eg. interest、 altitude、IQ、 personality)

Worksite Job evalu.

Work hardening

Exercise & training

RTW


questionnaire and telephone interview to 390 patients occupational injury workers hospitalized

followed 3 to 6 months - cause of their injury, medical treatment process, rehabilitation condition, return to work status, the compensation or subsidiary awarded

34 % of the injured workers are not back to their former job, of them more than one third were even with poor medical recovery

employees already return to work - residual pain is usually a problem and demand for health and compensation information

The Center for Management of Occupational Injury and Disease (CMOID), NTUHExtramural surveillance program


Factors affecting return to work for workers with occupational upper extremity fracture - 110 patients with telephone interview

Censored at six month - more than 20 % of workers unable to return to work

the most important factors are fracture site, without fixed employer, and poor self perceived workability

timely ambulance to the hospital, compensation assistance, functional capacity evaluation - influential

though quality of life improved with time, not all the four domains, physiological, psychological, social, and environmental aspects presented a consistent progress (WHOQOL)

The Center for Management of Occupational Injury and Disease (CMOID), NTUH~ Epidemiological study


an integrated health care model –unification of prevention, compensation and return-to-work is expected to meet the purpose of protecting occupational injured workers

Generalizability to different health conditions, eg. lower extremity injury, occupational low back pain may be needed

other key issues – disability phases, settings, improving measurement instruments

combining research methods- satisfaction, demand/supply, cost/effectiveness

Successful Return To Work

John- Hopkins COEH study of before(1989-1992) and after RTW program(1993-1999):

reduction of workday loss55 % injury workers proportion from 26.3% down to

12 % Partial workability recovery proportion from

0.63 % up to 13.4 % Case management cut down the cost of

compensation 23% Joint effort of occupational physician, nurse, case

manager, safety specialist, insurance company, employee and injured worker


General health care to the workers has focused more on treatment; prevention is not part of many clinical health practices

PCR is a multi-disciplinary team work to meet the diversified needs of the working population

PCR is evidence-based and coincide with WHO, public health spirit

efficiently incorporating worker-centered case management health care delivery

technical development and in-depth research warranted


To intervene and to reduce the economic and social impact would be the destiny of occupational & environmental medicine

It is expected through effective surveillance and PCR model, we would be able to improve the well-being of those workers who are unfortunately injured in the workplace

Principles of management of occupational and environmental diseases: prevention, compensation, and return-to-work Chung-Li Donald Du, Center for Management.

Documents

human health

occupational hazard

important health problem

health circle notes

control of health hazards

ilo slide

perspective slide

humans slide