Principles of management of occupational and environmental by P3y0f4E3


									Principles of management of
     occupational and
  environmental diseases:
prevention, compensation, and
                 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
 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
 WHO charter: Health is a state of
 complete physical, mental and
 social well-being and not merely
 the absence of disease or
  Occupational and environmental
    factors in the health circle

                           Living and working conditions
                           may include:

                           • Psychosocial factors
                           • Employment status and
                           occupational factors
                           • Socioeconomic status (income,
                           education, occupation)
                           • The natural and built c
Over the life span         environments
                           • Public health services
                           • Health care services

                     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 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
 The newly used chemicals developed by
  industries are even seldom tested for toxicity
  for animals or humans
     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
   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
 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
   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
Occupational mortality - disease more
  than injury related to occupation

                                                                                  1 Disabling Injury
ILO     Deaths attributed to work
                                                    17%                         30 LWC
             19% Accidents
           0%                                     Comm.dis.
                                                                            300 Recordable
      23% Circul.                                       32% Cancer
                             7% Respir.
 Communicable diseases                    Cancer                           30,000 Near
 Respiratory Diseases                     Circulatory diseases             Misses
 Mental Disorders                         Digestive systems diseases
 Genitourinary system                     Accidents and violence       300,000 At-Risk Behaviors
            Taiwan’s occupational disease
             Statistics of Asian occupational disease 1990-1997
                 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   11,95   10,842   9,630   9,915   9,230
Thailand          ---     ---     62      116     125      51

Malaysia          77     502     2,942
South           2,995    2,841   2,824    3,145
   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
         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
 strain, sprain, tendonitis, bursitis, myositis,
  arthritis - usually produced by repeated movement
  and muscle strain.
                    Gradual increase of occupational
                    injury temporary disability cases
                                                (1990~2002, BLI)
           280000                                                                                                     Occupa
           250000                                                                                                     injuri
           240000                                       National                                                      es and
           230000                                        Health                                                       diseas
           220000                                      Insurance
           210000                                                                                                     es
           170000                                                                                                     Actual
           160000                                                                                                     paymen
Nu mb er   150000
                                                                                                                      t for
           130000                                                                                                     injuri
           120000                                                                                                     es and
           90000                                                                                                      es
                    1990   1991   1992   1993   1994    1995       1996   1997   1998   1999   2000   2001   2002
             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$
              Increased percentage of occupational injury
                  among total injury related temporary
                      disability (1990~2002, BLI)
  2000                                                                     injuri
                                                                           es and
Year                                                                       diseas
  1998                                                                     es


  1995                                                                     Actual
  1994                                                                     paymen
                                                                           t for
  1992                                                                     es and

         0%   10%   20%   30%   40%   50%   60%   70%   80%   90%   100%
            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
 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
   1996-1999Cost due to hospitalization              Fracture

  2.5                          2.10          2.49    Open wounds of
     2              1.77                             upper extremity

  1.5      1.42                                      Rolling over
            0.86       0.89       0.99
     1                                      1.17
            0.92        0.84       0.93       0.64   Burn
  0.5       0.24    0.26        0.33
           0.19         0.21    0.30         0.35
     0                                               Head trauma
 Million    1996   1997        1998       1999

     Meanwhile, Labor insurance compensation
     claim also increase dramatically !!
 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
    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
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
 reporting of occupational injury - employer
 reporting of occupational illness -
    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
    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 &
 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.
     Occupational health care &
 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)
     Occupational health care &
 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.
     Occupational health care &
 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
     Occupational health care &
 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
 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
  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
  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”
  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
  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
PCR case management model
  PCR---   Prevention
            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
                                ~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
 Workability evaluation
  technique and occupational
  Case Demand &
   Management                    Physical examination
                                 Job evaluation
 Occupational disease           Medical consultation
                                 Special exam.
  diagnosis                      Factory walkthrough
 Treatment of injury and
  disease                                                     Drugs
 Prevention of          Health screen                       O.T
                         Safety advise                       other
  occupational injury    & education
 RTW demand

 Compensation demand                 Certification
                                      Free charge of visit
                                      Support resources
Seven ways of reactive prevention of
    occupational injury/disease
 Health screening
 Surveillance
 Occupational disease
   Disability evaluation
   Worksite visit
   Case management and
   Epidemiological study
Prevention by Health Screening Process to
            Factory workers
            exposure and HE items

           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
           DOH, Taiwan
                               NTUH Surveillance

   疑似重金屬中毒、 鉛中毒 、砷       Electrical & Chemical burns
    中毒、 錳中毒、 黃磷中毒 汞
    中毒、 鉻中毒、疑似氣體、蒸        Intoxication/pesticide
    氣危害                   Occupational asthma, T.B.,
   疑似異常氣壓疾病                 allergic pneumonitis,
   疑似農藥中毒                   dermatitis
   疑似皮膚病                   Hand injury (cut, tear,
   疑似外傷                     compression)
   疑似塵肺症                   Amputation/fracture
   疑似聽力損害                  Musculoskeletal disorder
   疑似腕隧道症候群                Young stroke, CVD
   疑似針扎事件
   疑似肌肉骨骼傷害
                            HIVD, Peripheral
   疑似職災死亡
   其他與環境或職業相關疾病            Others
      CMOID OPD statistics
             OM OPD first visit                       distribution of first visit (92-4Q)

150                                                                                     medical
100                               patient no.   24%                                     jurisdiction
 0                                               6%                                     RTW
      92- 92- 92- 92- 93-                                    28%
      1Q 2Q 3Q 4Q 1Q

                                                                                                  Solvent expo.

                    registration, compiling, advise,

                      communication & follow-up


Cases Management:





                                                                                  4               noise

                                                                                                  Mental Stress


                                                                                                  Needle stick







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

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

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