Principles of management of occupational and environmental diseases: prevention, compensation, and return-to-work

1. Principles of management of occupational and environmental diseases: prevention, compensation, and return-to-work Chung-Li Donald Du, Center for Management of Occupational Injury and Diseases, National Taiwan University Hospital Jung-Der Wang Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health

2. 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

3. Health • WHO charter: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity

4. Broad social, economic, cultural, health, and environmental conditions and policies at the global, national, state, and local levels • 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 Living and working conditions a Social, family and community networks Individual behavior Innate individual traits: age, sex, race, and biological factors --- The biology of disease Over the life span b NOTES: Adapted from Dahlgren and Whitehead, 1991. The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman, 1999). Occupational and environmental factors in the health circle

5. 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

6. Occupational Health Status • 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

7. Occupational Health Status • “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

8. Occupational Health Status • 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

9. Occupational mortality - disease more than injury related to occupation Fatality, Disabling Injury 1 ILO 30 LWC 300 Recordable 30,000 Near Misses 300,000 At-Risk Behaviors

10. Taiwan’s occupational disease underestimated Statistics of Asian occupational disease 1990-1997

11. Occupational Health Status • 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

12. 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.

13. National Health Insurance

14. 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$

16. 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

17. medical expenses of five main occupational injury after NHI Meanwhile,Labor insurance compensation claim also increase dramatically !!

18. 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

19. Occupational Medicine specialty • 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

20. Occupational Medicine specialty • 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

21. Occupational Medicine specialty • 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

22. 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

23. 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.

24. Occupational health care & Management • 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

25. 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)

26. Occupational health care & Management • 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.

27. Occupational health care & Management • 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

28. Occupational health care & Management • 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

29. 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

30. Notification or surveillance of occupational injury and diseases • 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

31. Notification or surveillance of occupational injury and diseases • 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”

32. 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

33. From ad hoc system to prevention, compensation & RTW integration • 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

34. 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

35. Center for Management of Occupational Injury & Disease ~Since Apr,26,2003 • 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

36. Case Demand & Management • Physical examination • Job evaluation • Medical consultation • Special exam. • Factory walkthrough • Occupational disease diagnosis • Treatment of injury and disease • Prevention of occupational injury • RTW demand • Compensation demand • Drugs • P.T • O.T • other • Health screen • Safety advise & education • Work hardening • negotiation • Certification • Free charge of visit • Support resources

37. Seven ways of reactive prevention of occupational injury/disease • Health screening • Surveillance • Occupational disease diagnosis • Disability evaluation • Worksite visit • Case management and counseling • Epidemiological study

38. Qualified medical screening / assurance Computerization of database Personal health evaluation Action：weight reduction、quit smoking、body fitness Prevention by Health Screening Process to Factory workers walkthrough exposure and HE items questionnaire screening of possible exposure workers chronic illness factors evaluation  data management (risk assessment） follow up and health promotion

39. 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 DOH, Taiwan NTUH Surveillance

40. CMOID OPD statistics

41. Cases Management: registration, compiling, advise, communication & follow-up 16 12 8 4 PE Pneumoconiosis Needle stick chemical Mental Stress fracture noise jurisdiction retinopathy CTS Amputation HIVD dermatitis insomnia RSI Solvent expo. fascistic T.B

42. Worksite Job evalu. W.E need verified by Physician or OT Job Hx.content analysis、ADL、Pain、FCE & other tests (eg. interest、altitude、IQ、personality) Work hardening Refer for physical training Exercise & training RTW Disability Evaluation & Return To Work flowchart

43. From ad hoc system to prevention, compensation & RTW integration • 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), NTUH Extramural surveillance program

44. From ad hoc system to prevention, compensation & RTW integration • 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

45. From ad hoc system to prevention, compensation & RTW integration • 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

46. 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

47. PCR model and perspective • 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

48. PCR model and perspective • 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 Thank you for your attention!

49. To Keep Health Equity & Safe Healthy Work Environment!