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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 WangInstitute of Occupational Medicine and Industrial Hygiene,Natio
2、nal Taiwan University College of Public Health,Outline,Occupational health Occupational injuryOccupational medicine as a specialtyOccupational health care and managementNotification or surveillance of occupational injury and diseases From ad hoc system to prevention,compensation,return to work(PCR)i
3、ntegration in Taiwan PCR model and perspective,Health,WHO 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 factors in the health circle,Occupational Health Status,rapid proliferation of new i
4、ndustrial 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,Occupational Health Statu
5、s,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 in
6、fected persons,with infected animal or human tissue,secretions,or excretions,Occupational Health Status,“ergonomics”or human factor engineering has been introduced into the workplaceworkers health problem arise from designs of workstations,tools,equipments or work proceduresphysical agents such as n
7、oise 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
8、 stress response or make diagnosis of work stress related psychological and physiological disability is poorthe number of compensation claim of work related circulatory disease increasedworkplace wellness and occupational health education program evolvedquit smoking,healthy diet,exercise,stress mana
9、gement 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 Injury,1,ILO,Taiwans occupational disease underestimated,Statistics of Asian occupational disease 1
10、990-1997,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 o
11、ne 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 m
12、ost common occupational injuries involve musculoskeletal system or musculoskeletal diseases strain,sprain,tendonitis,bursitis,myositis,arthritis-usually produced by repeated movement and muscle strain.,NationalHealthInsurance,Occupational Injury,According to BLI,the percentage of occupational injury
13、 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$in direct workers compensation costs indirect cost:production delays,damage to
14、 equipment,and recruiting and training replacement workersestimated to be five times,or about 30 billion NT$,Occupational Injury,Workers compensation benefits-permanent total disability,temporary total disability,permanent partial disability,temporary partial disability,and survivors benefits.In Tai
15、wan,only lump sum but no annuity paid to the insured worker.During rehabilitation period,only sick leave or designated auxiliary tools for handicapped are offeredno vocational or psychological counseling or retraining or job placement assistance,compared to United States or most European countries,m
16、edical expenses of five main occupational injury after NHI,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 a
17、cquiring a wretched disease that would make ones work a curse rather than a lovediseases of metal digger,painters,midwives,glassmakers,potters,sewer workeraffliction by inhaling noxious gases and dusts,or from disorderly motions and improper postures of the body,Occupational Medicine specialty,the p
18、rimary care physician have taken the responsibility of health care for the industry workers compensation issues usually followed after treatmentoccupational compensation system emerged from Germany since mid-19 centurystate(or government)run vs.private insurance carriersmost are compulsory,and even
19、with penalties for not having insurance,Occupational Medicine specialty,The employers 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 authoritiesr
20、eporting of occupational injury-employerreporting of occupational illness-physicians,Occupational Medicine specialty,occupational physician system accompanied the progress and change of industrynew legislation to protect the workers health and enhance their benefitshigh-tech ages-labor force subject
21、ed 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 occ
22、upational hazard-stress and related disease,musculoskeletal disorderoccupational 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 healthto serve for both
23、the employer and employeeto 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
24、of health care serviceTaiwan-National Health Insurance system,cover nearly all hospitals and clinics.,Occupational health care&Management,clinical managed care-to change the number or mix of services provided and to reduce the price paid for servicecase management is a process,one component in the m
25、anaged care strategythe 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 collaborativ
26、e process which assesses,plans,implements,coordinates,monitors,and evaluates the options and services required to meet an individuals health needs,using communication and available resources to promote quality,cost-effective outcomes.”major areas of activity-medical,financial,behavioral/motivational
27、,vocational,the Commission for Case Manager Certification(CCMC),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
28、 in1987 was later amended and renamed as“Workplace Injury Management and Workers Compensation Act”in 1998.,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
29、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&Management,All parties-the insurer,employ
30、er,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,provis
31、ion 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 in
32、jured worker are eligible for compensation Most occupational compensation system have an effective reporting systemno 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,Notif
33、ication 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 r
34、eported.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 Univer
35、sity Hospital,an in-hospital emergency room(ER)surveillance system was started since last Sep(2003)ER:chemical injury,eye injury,occupational trauma,electrocutions and welders disease.Taipei county government independent law in 2002 to punish those employer or practicing physicians within geographic
36、al boundary not to report occupational diseaseIn 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 diseas
37、e 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-restric
38、tion 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 injurya large proportion(38%)of injured workers experience a
39、 reinjury after returning to workmany 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,PC
40、R case management model,PCR-Prevention Compensation Rehabilitation(Return-to-work)Benefits as:reduction of injury with disabilityencouraging return to worksave medical and insurance cost,Center for Management of Occupational Injury&Disease,Joint collaboration among Council of Labor Affairs(Bureau of
41、 Labor Insurance)and the hospitalDevelop intra-and extra-mural surveillance systemSetup of standard diagnosis and case management modelWorkability evaluation technique and occupational rehabilitation,Since Apr,26,2003,Case Demand&Management,Occupational disease diagnosisTreatment of injury and disea
42、sePrevention of occupational injuryRTW demand Compensation demand,Physical examinationJob evaluationMedical consultation Special exam.Factory walkthrough,DrugsP.TO.Tother,Health screenSafety advise&education,Work hardeningnegotiation,CertificationFree charge of visitSupport resources,Seven ways of r
43、eactive prevention of occupational injury/disease,Health screening SurveillanceOccupational disease diagnosisDisability evaluationWorksite visitCase management and counseling Epidemiological study,Prevention by Health Screening Process to Factory workers,walkthrough exposure and HE items questionnai
44、re,screening of possible exposure workers chronic illness factors evaluation data management(risk assessment）follow up and health promotion,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 burnsIntoxication/pestic
45、ideOccupational asthma,T.B.,allergic pneumonitis,dermatitisHand injury(cut,tear,compression)Amputation/fractureMusculoskeletal disorderYoung stroke,CVDHIVD,Peripheral neuropathyOthers,NTUH Surveillance,DOH,Taiwan,CMOID OPD statistics,Cases Management:registration,compiling,advise,communication&follo
46、w-up,fascistic,PE,Pneumoconiosis,Needle stick,chemical,Mental Stress,fracture,noise,jurisdiction,retinopathy,CTS,Amputation,HIVD,T.B,dermatitis,insomnia,Solvent expo.,RSI,4,8,12,16,Disability Evaluation&Return To Work flowchart,From ad hoc system to prevention,compensation&RTW integration,questionna
47、ire 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 awarded34%of the injured workers are not back to their former job,
48、of them more than one third were even with poor medical recoveryemployees 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
49、system to prevention,compensation&RTW integration,Factors affecting return to work for workers with occupational upper extremity fracture-110 patients with telephone interviewCensored at six month-more than 20%of workers unable to return to workthe most important factors are fracture site,without fi
50、xed employer,and poor self perceived workabilitytimely 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 p
