Time and knowledge barriers to recognizing occupational disease

Informatics Approaches for Recognition, Management, and Prevention of Occupational Respiratory Disease

Computer and information systems can improve occupational respiratory disease prevention and surveillance by providing efficient resources for patients, workers, clinicians, and public health practitioners. Advances include interlinking electronic health records, autocoding surveillance data, clinical decision support systems, and social media applications for acquiring and disseminating information. Obstacles to advances include inflexible hierarchical coding schemes, inadequate occupational health electronic health record systems, and inadequate public focus on occupational respiratory disease. Potentially transformative approaches include machine learning, natural language processing, and improved ontologies.

A Framework for Integrating Environmental and Occupational Health and Primary Care in a Postdisaster Context

CONTEXT

Integration of environmental and occupational health (EOH) into primary care settings is a critical step to addressing the EOH concerns of a community, particularly in a postdisaster context. Several barriers to EOH integration exist at the physician, patient, and health care system levels.

PROGRAM

This article presents a framework for improving the health system's capacity to address EOH after the Deepwater Horizon oil spill and illustrates its application in the Environmental and Occupational Health Education and Referral (EOHER) program. This program worked with 11 Federally Qualified Health Center systems in the Gulf Coast region to try to address the EOH concerns of community members and to assist primary care providers to better understand the impact of EOH factors on their patients' health.

IMPLEMENTATION

The framework uses a 3-pronged approach to (1) foster coordination between primary care and EOH facilities through a referral network and peer consultations, (2) increase physician capacity in EOH issues through continuing education and training, and (3) conduct outreach to community members about EOH issues.

EVALUATION

The EOHER program highlighted the importance of building strong partnerships with community members and other relevant organizations, as well as high organizational capacity and effective leadership to enable EOH integration into primary care settings. Physicians in the EOHER program were constrained in their ability to engage with EOH issues due to competing patient needs and time constraints, indicating the need to improve physicians' ability to assess which patients are at high risk for EOH exposures and to efficiently take environmental and occupational histories.

DISCUSSION

This article highlights the importance of addressing EOH barriers at multiple levels and provides a model that can be applied to promote community health, particularly in the context of future natural or technological disasters.

Wounding the Messenger: The New Economy Makes Occupational Health Indicators Too Good to Be True

The U.S. Bureau of Labor Statistics and workers' compensation insurers reported dramatic drops in rates of occupational injuries and illnesses during the 1990s. The authors argue that far-reaching changes in the 1980s and 1990s, including the rise of precarious employment, falling wages and opportunities, and the creation of a super-vulnerable population of immigrant workers, probably helped create this apparent trend by preventing employees from reporting some injuries and illnesses. Changes in the health care system, including loss of access to health care for growing numbers of workers and increased obstacles to the use of workers' compensation, compounded these effects by preventing the diagnosis and documentation of some occupational injuries and illnesses. Researchers should examine these forces more closely to better understand trends in occupational health.

How physicians allocate causation: a scenario study with factorial design

BACKGROUND

Causation is a complex concept but important in suspected work-related disease. Physicians routinely make initial assessments of causation as part of their work, but the factors contributing to these assessments are not well understood.

AIMS

To determine which factors influence a family physician's assessment of causation when seeing patients with suspected work-related injury or illness.

METHODS

Four groups of family physicians with differing levels of prior reporting (zero, low, medium, high) to the Workers Compensation Board received a questionnaire including four randomly allocated case scenarios. For each scenario there were four versions with either strong or weak causal features suggesting work or non-work factors were important causes or contributors. Responses to questions were made on a series of visual analogue scales.

RESULTS

The nature of the condition and scenario type (i.e. strength of the causal information about workplace and non-workplace factors) were associated with the physicians' opinion on work-relatedness. Understanding the nature of the patient's work, the timing of symptoms and the patients' opinion about work-relatedness were viewed by the physicians as important. A decision that a condition was not work related was influenced primarily by the strength of potential causes outside work. Prior reporting history of the physician was not associated with opinions on work-relatedness, nor the factors considered in reaching this decision.

CONCLUSIONS

The characteristics of the case scenario were more important in determining a physician's opinion about work-relatedness than the characteristics of the physician.

Barriers to the recognition and reporting of occupational asthma by Canadian pulmonologists

BACKGROUND

Occupational asthma is a common, but probably under-recognized problem.

OBJECTIVE

To identify the factors that suggest work-related asthma when a pulmonologist encounters an adult patient with new-onset asthma, and to identify the barriers to recognizing and reporting such cases.

METHODS

A postal questionnaire was sent to all pulmonologists in Canada. The questionnaire asked participants to respond to several questions about recognizing, diagnosing and reporting occupational asthma. Answers were scored using visual analogue scales.

RESULTS

A total of 201 eligible responses were received from 458 pulmonologists. Pulmonologists identified that the most important factor in initially considering the role of work in occupational asthma was having seen others affected at the same workplace, or exposed to the same agent. Important perceived barriers to considering a diagnosis of occupational asthma were physicians' low awareness, lack of knowledge and time. The most important barriers to reporting cases were the pulmonologists' perceived patient concerns regarding job security and income. Quebec pulmonologists generally perceived barriers to recognizing and reporting occupational asthma to be less important, and believed that the use of specific inhalation challenge was more important in considering a diagnosis.

CONCLUSIONS

Pulmonologists most readily recognized occupational asthma caused by a substance or process that they previously encountered as a possible cause of asthma. Time constraints and knowledge may hamper their ability to recognize occupational asthma. Concerns regarding the effect of the diagnosis on the patient's job and income may discourage reporting.

Different reporting patterns for occupational diseases among physicians: a study of French general practitioners, pulmonologists and rheumatologists

PURPOSE

Physicians can play an important role in the reporting of occupational diseases (ODs), which are still under-reported in many countries. We aimed to identify physicians' difficulties in recognizing and reporting ODs and to study the characteristics of the physicians that do report ODs.

METHODS

We conducted a telephone study in 2006-2007 among general practitioners (GPs), pulmonologists and rheumatologists in south-eastern France, concerning their knowledge, attitudes and practice in occupational health. Simple and multiple logistic regressions were performed to study factors associated with the issue of medical certificates for the claim process.

RESULTS

Three hundred and ninety-one GPs, 95 pulmonologists and 96 rheumatologists participated. GPs reported significantly less often than specialists that they questioned their patients on past occupational exposure. They more frequently reported difficulties in identifying the occupational origin of diseases, and lack of knowledge on the OD reporting system. Issue of medical certificates for OD reporting was significantly more frequent among specialists than among GPs, among physicians considering that ODs are a public health problem, among those acquainted with the forms required to establish certificates, using internet to obtain information, having trade union activities, or having contact with occupational physicians (OPs).

CONCLUSION

Initial and continuing training should be developed to encourage physicians, in particular GPs, to question patients on their working conditions and to become better acquainted with claim procedures. Physicians should also be provided with tools for identification of ODs that are suited to their practices, and collaboration with OPs should be fostered.

Barriers to physician reporting of workers' compensation cases in France

Studies suggest strong underreporting of occupational diseases in industrialized countries. We studied physician-related barriers to reporting of occupational sciatica (with herniated disk). We conducted a telephone survey of 391 general practitioners (GPs) and 96 rheumatologists in southeastern France with a standardized questionnaire and case-vignette of a patient with occupational sciatica. Our results show that 71% of GPs and 78% of rheumatologists would not recommend that the case-vignette patient file a workers' compensation claim, for the following reasons: possible role of nonwork-related activities (77%, 74%), should be reported as an occupational accident (67%, 42%), recommendation should be made by occupational physicians (60%, 60%), and risk of patient's losing his job (47%, 38%). Our results suggest that occupational sciatica is underreported in France. Physicians' lack of knowledge of reporting principles and procedures and their ethical dilemma regarding job loss may be barriers to reporting.

Practice Patterns of Pulmonologists and Family Physicians for Occupational Asthma

BACKGROUND

The longer the duration of symptoms of occupational asthma (OA) before diagnosis, the poorer the outcome. Physicians can play a key role in the early recognition of occupational lung diseases (OLDs), including OA. Our objective was to document and compare the practice patterns, barriers, and needs for early diagnosis of OA among pulmonologists and family physicians.

METHODS

Based on information from the literature and interviews with pulmonologists and family physicians, a survey was developed to obtain information on practice patterns. The survey was sent to all pulmonologists and a random sample of 600 family physicians in Ontario.

RESULTS

Eight percent of pulmonologists and 7% of family physicians report seeing >20 patients a year with OLD. The majority report taking a workplace exposure history. The most commonly stated barrier to obtaining a workplace exposure history was time constraints. Main reasons for referral to specialists for diagnosis include personal lack of expertise, testing facilities, and knowledge about workers' compensation, while lack of timely access to specialists is a barrier for referral. While most physicians identified a need for further education, those who did not identify a need for further occupational respiratory education cited low volume of patients, access to specialists, and time constraints as reasons for not wanting further education.

CONCLUSIONS

Opportunities are identified to improve health services delivery and educational initiatives for OA, with approaches tailored to each particular physician group.

Dermatologist and family practitioner practice patterns for occupational contact dermatitis

Medical practitioners have a role in the recognition of occupational contact dermatitis. The longer the duration of symptoms before diagnosis, the poorer the outcome. Our objective was to understand practice patterns, barriers and needs for early diagnosis of occupational contact dermatitis. A survey to obtain information on practice patterns was developed based on the literature and interviews with dermatologists and family practitioners. The survey was sent to all dermatologists and a random sample of 600 family practitioners in Ontario. Fifty-seven per cent of dermatologists and 9% of family practitioners report seeing more than 20 patients per year with occupational contact dermatitis. The majority of practitioners report taking a workplace exposure history. Barriers to taking a workplace exposure history include time constraints and lack of knowledge. Reasons for referral to specialists include a lack of expertise, testing facilities and knowledge about workers' compensation, time constraints and inadequate reimbursement, whereas lack of access to specialists is a barrier for referral. Although most practitioners identify a need for further education, a low volume of patients and time constraints are key barriers to continuing education. Opportunities are identified to improve educational initiatives and health services delivery for occupational contact dermatitis, tailored to each practitioner group.

Computer algorithm for automated work group classification from free text: the DREAM technique

OBJECTIVE

This study developed and tested a computer method to automatically assign subjects to aggregate work groups based on their free text work descriptions.

METHODS

The Double Root Extended Automated Matcher (DREAM) algorithm classifies individuals based on pairs of subjects' free text word roots in common with those of standard classification systems and several explicitly defined linkages between term roots and aggregates.

RESULTS

DREAM effectively analyzed free text from 5887 participants in a multisite chronic obstructive pulmonary disease prevention study (Lung Health Study). For a test set of 533 cases, DREAMs classifications compared favorably with those of a four-human panel. The humans rated the accuracy of DREAM as good or better in 80% of the test cases.

CONCLUSIONS

Automated text interpretation is a promising tool for analyzing large data sets for applications in data mining, research, and surveillance. Work descriptive information is most useful when it can link an individual to aggregate entities that have occupational health relevance. Determining the appropriate group requires considerable expertise. This article describes a new method for making such assignments using a computer algorithm to reduce dependence on the limited number of occupational health experts. In addition, computer algorithms foster consistency of assignments.

Quality of occupational history assessments in working age adults with newly diagnosed asthma

BACKGROUND

Approximately 10 to 15% of new-onset asthma in adults is attributable to occupational exposure. The occupational history is the most important instrument in the diagnosis of occupational asthma (OA).

STUDY OBJECTIVES

To assess the quality of occupational histories obtained by health-care providers and to measure the prevalence of clinician-diagnosed OA in a population at elevated risk for OA.

SETTING

An academic US Department of Veteran Affairs medical center.

STUDY POPULATION

One hundred ninety-seven adults (age range, 18 to 55 years) with newly diagnosed asthma who had completed pulmonary function testing (PFT) and a structured respiratory health questionnaire.

MEASUREMENTS

We conducted a structured retrospective comparison of occupational respiratory health history documented by clinicians with data documented by patients on a structured questionnaire. We analyzed PFT results to assess physiologic impairment. We also conducted a structured examination of the actions taken by health-care providers based on their occupational history assessments.

RESULTS

Patient self-reports of respiratory exposures and symptoms were common. A job title was documented by one or more clinicians in 75% of patient medical records. Additional occupational history data were charted much less frequently. A diagnosis of OA was made in only 2% of patients. Clinical action to address OA was documented for only one patient.

CONCLUSIONS

Clinicians who manage adults with newly diagnosed asthma take incomplete occupational histories. We detected discordance between the occupational exposure histories documented by patients and those charted by clinicians. OA may go unrecognized and possibly undermanaged by clinicians.

Certification of occupational diseases as common diseases in a primary health care setting

BACKGROUND

It is often difficult to discern whether a disease is an occupational or common disease, especially in a primary care setting.

METHODS

From a randomly selected sample of 322 workers attending a Primary Health Care Center, 207 workers (response rate of 64.3%) agreed to participate. An occupational questionnaire was administered. General practitioners provided medical records for each worker. Medical records and occupational questionnaires were independently reviewed by three professionals. They assessed whether a relationship between disease and working conditions was probable or improbable.

RESULTS

Thirty-three of the 207 cases (15.9%) were considered probably related to working conditions according to the expert's opinion. The most frequent were musculoskeletal diseases (20 cases). Of the 207 workers, 74 (35.7%) judged that their diseases could be related to their working conditions.

CONCLUSIONS

A significant proportion of diseases attended in primary care setting was not recognized as occupational, and they were hence not reflected in official statistics.

Frequency of occupational health concerns in general clinics

Studies have suggested that occupational disease and injury are under-recognized by clinicians. To estimate the frequency of occupational factors in disease and injury, 108 patients in a general (not occupational) health care facility were interviewed about the frequency and types of workplace-health interactions. Thirty-nine percent reported possible causation by work, and 66% reported a possible increase in symptoms by work, even if not caused by work. Twenty-seven percent reported changing jobs and/or tasks because of work-health interactions. The majority of men and women reported that worksite changes could improve their functional ability at work. This study therefore indicates that (1) occupational health concerns are common in primary care clinics, even if not addressed by clinicians; (2) the definition of occupational health concerns should be broadened to include disease caused by work, disease symptoms worsened by work, and the need for occupational accommodation even if the disease itself is not caused by work; and (3) inquiring about patient concerns about workplace-health interactions can provide clinicians with significant opportunities for primary, secondary, and tertiary prevention.