Advancing Value-Based Medicine: Why Integrating Functional Outcomes With Clinical Measures Is Critical to Our Health Care Future

Work Disability Prevention and Management

OBJECTIVE

This abbreviated version of the American College of Occupational and Environmental Medicine's (ACOEM) Work Disability Prevention and Management Guideline reviews the available evidence and provides recommendations to clinicians regarding interventions to help patients remain at or return to work.

METHODS

Systematic literature reviews were conducted. Studies were graded and evidence tables were created, with involvement of a multidisciplinary expert panel that evaluated the evidence and finalized recommendations for all clinical questions. Extensive peer review was performed. Consensus recommendations were formulated when evidence was lacking.

RESULTS

Evidence-based recommendations have been developed to guide work disability prevention and management.

CONCLUSIONS

Clinicians should utilize quality evidence in determining treatment methods to prevent and alleviate work disability for workers. This guideline offers an evidence-based framework for preventing and mitigating work disability for individual adults in the active workforce. It is designed for use by healthcare clinicians who desire to minimize the negative impact of health conditions on working people's lives and livelihoods.

RESTART: a stepped-care approach to facilitate return to work for employees with psychological distress: design of a randomized controlled trial

BACKGROUND

Common mental health problems, such as stress, anxiety and depression, are highly prevalent among workers and often lead to long-term absenteeism and work disability. Effective elements found in previous researched interventions were to explicitly focus on return to work (RTW) and not solely on symptom reduction, to take into account the employees' cognition towards RTW and to include the workplace environment. Based on these elements, a stepped-care approach was developed. The aim of this paper is to present the study design of a randomized controlled trial (RESTART), evaluating the effectiveness of the stepped-care approach on lasting RTW and the implementation process.

METHODS

RESTART is a randomized controlled trial with a 2 × 2 factorial design and a follow-up of one year. Employees eligible for this study are those who reported sick within 2 to 8 weeks with psychological distress based on a distress screener. Participants will be randomized to a group receiving a tailored e-Health app or usual care, as well as randomized to a group receiving a Participatory Approach (PA; conversational method) in the workplace or usual care. The PA will however only be provided in case of persistent sickness absence at 8 weeks. Measurements take place at baseline, after the e-Health intervention period (3 months), and after the PA intervention period (6 months) and 12 months. Primary outcome is lasting RTW, defined as full RTW in previous or equal work for at least four consecutive weeks. Secondary outcomes are (the severity of) stress-related symptoms, total number of sickness absence days, self-efficacy for RTW and self-reported health. A process evaluation including a realist evaluation will also be conducted.

DISCUSSION

Early intervention that focuses on RTW, the cognition towards RTW despite symptoms and involves the workplace environment, plays a crucial role in managing sickness absence among employees with psychological distress. If effective, the stepped-care approach is relevant for employees, employers and society as a whole.

TRIAL REGISTRATION

ISRCTN: 90663076. Registered on 5 October 2023.

The Future of Occupational and Environmental Medicine

ABSTRACT

Occupational and environmental medicine (OEM) is an ACGME-accredited preventive medicine specialty focused on work as a social determinant of health and population health. OEM providers recognize and mitigate workplace and environmental hazards, treat resultant injuries and illnesses, and promote the health, wellness and resiliency of workers and communities. Multidisciplinary residency training in clinical medicine, epidemiology, public and population health, toxicology, exposure and risk assessment, and emergency preparedness equips them with the skill set needed for leadership roles in diverse settings. These include clinical practice, academia, corporate settings, and governmental agencies. Despite robust job opportunities, a shortage of formally trained OEM physicians remains and is expected to worsen given a declining number of training programs. We examine root causes of the system-level issues impacting the supply of OEM physicians and potential solutions.

Dynamic prediction of work status for workers with occupational injuries: assessing the value of longitudinal observations

OBJECTIVE

Occupational injuries (OIs) cause an immense burden on the US population. Prediction models help focus resources on those at greatest risk of a delayed return to work (RTW). RTW depends on factors that develop over time; however, existing methods only utilize information collected at the time of injury. We investigate the performance benefits of dynamically estimating RTW, using longitudinal observations of diagnoses and treatments collected beyond the time of initial injury.

MATERIALS AND METHODS

We characterize the difference in predictive performance between an approach that uses information collected at the time of initial injury (baseline model) and a proposed approach that uses longitudinal information collected over the course of the patient's recovery period (proposed model). To control the comparison, both models use the same deep learning architecture and differ only in the information used. We utilize a large longitudinal observation dataset of OI claims and compare the performance of the two approaches in terms of daily prediction of future work state (working vs not working). The performance of these two approaches was assessed in terms of the area under the receiver operator characteristic curve (AUROC) and expected calibration error (ECE).

RESULTS

After subsampling and applying inclusion criteria, our final dataset covered 294 103 OIs, which were split evenly between train, development, and test datasets (1/3, 1/3, 1/3). In terms of discriminative performance on the test dataset, the proposed model had an AUROC of 0.728 (90% confidence interval: 0.723, 0.734) versus the baseline's 0.591 (0.585, 0.598). The proposed model had an ECE of 0.004 (0.003, 0.005) versus the baseline's 0.016 (0.009, 0.018).

CONCLUSION

The longitudinal approach outperforms current practice and shows potential for leveraging observational data to dynamically update predictions of RTW in the setting of OI. This approach may enable physicians and workers' compensation programs to manage large populations of injured workers more effectively.

ACOEM OEM Core Competencies: 2021

Competency is defined as possession of sufficient physical, intellectual, and behavioral qualifications to perform a task or serve in a role which adequately accomplishes a desired outcome. Recognizing the need for defining competencies essential to occupational and environmental medicine (OEM) physicians, the American College of Occupational and Environmental Medicine developed its first set of OEM Competencies in 1998. Later updated in 2008, and again in 2014, the increasing globalization and modernization of the workplace, along with published research on OEM practice, required an update to ensure OEM physicians stay current with the field and practice of OEM. Delineation of core competencies for the profession provides employers, government agencies, health care organizations, and other health practitioners a solid context of the role and expertise of OEM physicians.

Workers' Compensation Elements in Different Jurisdictions in the United States

: Over the decades, the workers' compensation system has provided many injured workers with a significant guarantee of both medical and financial support when they have been injured on the job. To be effective, workers' compensation systems at a minimum should include principles that require the addressing of medical causation, determination of an individual's functional ability both pre- and post-injury to include activity restrictions, return-to-work capability and disability, meeting jurisdiction-specific reporting requirements of the workers' compensation reporting requirements, and having knowledge of other perspectives of the various authorities and jurisdictions present in the United States. ACOEM lays out a description of various aspects of workers' compensations systems in the United States, with recommendations for minimal standards and best practices. This paper limits itself to the discussion of jurisdictions within the United States and ACOEM strongly recommends that providers consult directly with the states in which they are working as there are state variations in workers' compensation.

Utilization Review in Workers' Compensation: Review of Current Status and Recommendations for Future Improvement

: Utilization review (UR) is a process that assesses aspects of a treating provider's care plans and then provides recommendations to payors/insurance carriers, third party administrators, etc, concerning the appropriateness of the proposed care. UR has become an integral part of medical practice and has influenced medical care within the workers' compensation (WC) system and is mandated in several states and jurisdictions. This guidance statement from the American College of Occupational and Environmental Medicine (ACOEM) reviews structural elements of UR programs and proposes a possible template for operational standards. UR has a unique role in protecting patients and educating providers on evidence-based guidelines, new research, and best practices.

Health Care Expenditures and Length of Disability Across Medical Conditions

Objective:

To describe the relationship between the length of short-term disability (STD) and health care spending.

Methods:

Medical claims for insured US employees on STD were evaluated to describe the distribution of disability durations and health expenditures across major diagnostic categories and common medical conditions. Correlations between health expenditures and disability durations were examined.

Results:

The most expensive 10% of cases accounted for more than half of total health spending. The longest 10% of cases accounted for more than one-third of total disability time. Only one-third of the most expensive cases were also among the longest in duration. Disability durations were moderately correlated with medical spending and this relationship was modified by comorbid conditions and age.

Conclusion:

Psychosocial barriers, in addition to biomedical factors, should be considered to achieve optimal functional outcomes and well-being of patients.

Primary Care Occupational Therapy: How Can We Get There? Remaining Challenges in Patient-Centered Medical Homes

Passage of the Patient Protection and Affordable Care Act in 2010 mandated reform of the United States' existing primary care system. As part of this reform, advanced practice models, including the Patient-Centered Medical Home model, expanded, with the goal of increasing the use of interprofessional teams. Integrating occupational therapy was promoted as an opportunity to enhance the value of care provided in these redesigned primary care practices. However, occupational therapy's presence in primary care is still extremely limited.

Efficacy of Age-Specific High-Intensity Stretch-Shortening Contractions in Reversing Dynapenia, Sarcopenia, and Loss of Skeletal Muscle Quality

During the aging process, skeletal muscle performance and physiology undergoes alterations leading to decrements in functional capacity, health-span, and independence. Background: The utility and implementation of age-specific exercise is a paramount research agenda focusing on ameliorating the loss of both skeletal muscle performance and physiology; yet, to date, no consensus exists as to the most appropriate mechanical loading protocol design or overall exercise prescription that best meets this need. Thus, the purpose of this review is to highlight the most optimal type of exercise presently available and provide the most current, evidence-based findings for its efficacy. The hypothesis that high-intensity, stretch-shortening contractions (SSCs)-a form of "resistance-type exercise" training-present as the preferred exercise mode for serving as an intervention-based modality to attenuate dynapenia, sarcopenia, and decreased muscle quality with aging, even restoring the overall youthful phenotype, will be demonstrated. Conclusions: Appreciating the fundamental evidence supporting the use of high-intensity SSCs in positively impacting aging skeletal muscle's responsivity and their use as a specific and sensitive countermeasure is crucial. Moreover, from an applied perspective, SSCs may improve skeletal muscle quality and rejuvenate health-span and, ultimately, lead to augmented functional capacity, independence, and quality of life concomitant with decreased morbidity.