[Evidence based occupational health: from theory to practice]

BACKGROUND

Health care organizations are increasingly aware of the need to apply quality assurance principles to serve their mission and there is an increasing pressure on health professionals to ensure that the practice be based on evidence of appropriateness. Therefore, medical specialists of different disciplines, including occupational health, are presently required to shift from habitual practices to evidence-based practices.

OBJECTIVE AND METHODS

This paper aims at illustrating the opportunity offered by the Evidence Based Medicine (EBM), which can be used in the decision making process of the occupational physician according to the Evidence Based Occupational Health (EBOH) paradigm. The EBOH approach consists of 4 steps (i) the formulation of the problem according to the PICO model, (ii) the search for scientific external evidence based on scientific papers and documents available in different database, (iv) the critical appraisal of such evidence, (v) the application of the evidence in the decision making process.

RESULTS AND CONCLUSIONS

In spite of some barriers, such as time constraint, which could prevent looking for searchable information, the evidence-based decision-making process should be based on the evidence provided by major resources to answer the question emerging during the practice. Acquiring the skill for information managing facilitates searching appropriate solutions to problems usually met during the professional practice and the adoption of behaviours which will improve the practice.

[Clinical and risk records assessment]

In the collaboration between the Hospital Occupational Health Department and Public Occupational Service of Bergamo, it has been elaborated a plan finalised to the verification of the quality and of the appropriateness in the compilation of the Clinical and Risk Record in the firm. The study has been lead by evaluation of 409 clinical and risk records (containing the first visit and, in 277 records, a periodic visit) collected from different productive areas (wood, building, health, agriculture). The analysis of the clinical and risk records have shown many critical aspects in their compilation, for this reason it is necessary to improve vigilance and attention from Public Occupational Service, Hospital Occupational Health Department and the Scientific Associations.

[Research and formal demonstration of evidence of efficiency in occupational medicine]

There is an increasing pressure on occupational health professionals to ensure that their practice is based on a quality standard and an evidence of appropriateness. The efficacy-effectiveness of their activity strictly depends on their intellectual and professional integrity, their technical and legal competence, but also on the quality of the relations with the company organisation they are able to establish. We asked to some occupational physician when they considered their interventions in the workplace to be efficacious. Then, accordingto our epexrience, we propose some effectiveness indicators, particular concerning health surveillance and health educttaon, that should be evaluated to verify the health professional agccvity agreement to quality standards.

[Quality assurance to efficacy-effectiveness measuring in occupational medicine]

The occupational medicine was asked to play an important role in quality assurance procedures as demonstrated by the implementation of main principles of prevention in ISO EMAS and SA schemes. Peculiar condition appeared to be the promotion of quality in occupational physician activities as, for example, provided in these last three years the Italian Society of Occupational Medicine and Industrial Hygiene (SIMLII) by its excellence accreditation programme. The next step will be the identification and application of adequate indicators of efficacy-effectiveness of occupational medicine practices to demonstrate need and role of our discipline in guaranteeing and improving health in working places. To these aims has been addressed the meeting held in Bergamo and organized by the Lombard section of SIMLII in December 2005 whose main contributions are published in this GIMLE special issue.

[Efficacy evidence in occupational medicine]

The author shows an overview of the most relevant features that characterize the development of the so-called "Evidence Based Occupational Health" (EBOH). After a short introduction dealing with the origin of the movement towards an evidence based medicine and health services, attributed to Donabedian and Vuori for WHO during the '80s on one hand, and, of course, fuelled by the most comprehensive Cochrane Collaboration, the most recent developments of EBOH both in Europe and in our country are discussed.

[Occupational epidemiology and efficiency evidence]

Occupational medicine is undergoing major changes and the question of "evidence" seems essential at this turning point. We need to update knowledge, adjust methods and verify the efficacy of interventions. If this is not done, the discipline might be reduced to just passive application of legislation with a consequent reduction of occupational medicine's professional and scientific content. Procuring evidence is objectively more difficult in the field of prevention than in the clinical field; however, those difficulties should be addressed and not simply handled in a trite way. In occupational medicine there is special opportunity to combine a "population" approach (tending to reduce exposure of the entire population) with a "high risk" approach where particularly susceptible subjects are identified and treated with targeted interventions. The contribution of epidemiology to the goal of underpinning a renewed occupational health practice with proves of evidence, mainly rests in suggesting methods able to (1) guarantee the validity of the observation of relationships between exposures and effects; (2) put together observations and studies independently conducted on the same issue and produce a combined quantitative evaluation; (3) set up ad hoc studies for evaluating prevention measures in progress. Health surveillance programs represent a particularly fertile soil for evaluation research and evidence accrual, however they are not sufficiently taken into consideration for this purpose, and relevant studies are few. A renewed cooperation involving occupational medicine and health centres is necessary to achieve that goal.

An independent AGREE evaluation of the Occupational Medicine Practice Guidelines

BACKGROUND AND CONTEXT

A large number of practice guidelines are being produced by numerous organizations. Health-care professionals need to critically evaluate these practice guidelines to understand whether they are well constructed and representative of the preponderance of evidence. The guideline development process should be precise and rigorous to ensure that the results are reproducible and not vague.

PURPOSE

To evaluate the quality of the second edition of the practice guidelines published by the American College of Occupational and Environmental Medicine (ACOEM Guidelines).

STUDY DESIGN/SETTING

Four appraisers used the AGREE (Appraisal of Guidelines Research and Evaluation) guideline evaluation instrument to evaluate the ACOEM Guidelines.

METHODS

The Guidelines were evaluated with the AGREE guideline evaluation instrument. The AGREE instrument has been widely adopted around the world, and the authors recommended that it be adopted as the standard of guideline construction process evaluation in the United States. The instrument standardizes the quantitative assessment of quality for a guideline's development process across six domains that include: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application, and editorial independence. Scores from four assessors were collected and interpreted. Additionally, each evaluator selected one of four global assessment choices: "strongly recommended for use in practice," "recommended for use with some modification or proviso," "not recommended as suitable for use in practice," or "unsure".

RESULTS

The ACOEM Guidelines scored highest in the dimensions that evaluated reporting of the guideline's scope and purpose (79.63) as well as clarity and presentation (86.81). The guideline scored much lower in the remaining areas that included stakeholder involvement (46.06), rigor of development (26.59), application (31.48), and editorial independence (19.17). The global assessment was unanimous with all four evaluators assessing the guideline as recommend with proviso.

CONCLUSIONS

Many of the Guidelines recommendations were consistent with current literature and guidelines; however, the AGREE assessment instrument evaluates the guideline development process and not the content. All the evaluators thought the content of the guidelines was substantially better than the documentation of the guideline construction process. The ACOEM Guidelines appear to have content consistent with their stated objectives, but the reporting of the guidelines construction process, particularly the rigor of recommendation development, is flawed, and the recommendations may not be valid owing to possible evidence selection deficiencies. The reader should consider these flaws and limitations when using the guideline. The reader should consider utilizing guidelines of higher quality when possible. Future guidelines should incorporate better reporting and give closer attention to guideline construction.

[Good practices and quality in the practice of occupational physicians]

This contribution describes practice and tools which allow occupational physicians the realization of theirs tasks not only respecting law and ethical codes, but also in view of a continuous improvement of their activities and customers (companies) and consumers (workers) care.

[Medycyna Pracy: the scopus-based analysis of citations]

Medycyna Pracy, a Polish bimonthly published since 1950, forms a long-standing documentation of studies carried out in the area of workers' health protection. The journal is primarily addressed to occupational health physicians and work hygiene specialists in Poland. It is indexed by numerous foreign information services (e.g., MEDLINE, EMBASE, BIOSIS PREVIEWS, BIOLOGICAL ABSTRACTS, SCOPUS) and thus promotes Polish research in occupational medicine throughout the world. The quantitative analysis for the years 1996-2005, grounded on the SCOPUS database, presents an average number of citations concerning a given volume, frequency of citations, articles most frequently cited, and countries, in which articles published in Medycyna Pracy have been referred to. A growing number of citations observed in the recent years signify the importance of issues investigated and discussed in the journal as well as its role in the world-wide circulation of scientific information.

[Efficacy in occupational medicine: proposals of the regional sections of SIMLII of Lombardy and Emilia Romagna]

The efficacy in Occupational Medicine is based on the degree of attainment of workers health and safety care. The Occupational Physician activity, attending on business parts, gives a contribution to the mission of the firm leading to the workers health/safety. The Occupational Physician actions are conditioned by workers features and by the other members of prevention system. It is necessary to verify the efficacy, the efficiency and the adequacy of the Occupational Physician activity finding goals and specific indicators.

[Quality and efficacy in occupational medicine: relationship between quality, efficacy, and surveillance -- Experience of public and private facilities in Emilia Romagna]

Italian legislation concerning health and safety at work establishes minimal requirements, according to European regulations. On the other side it's compulsory for Employers to set themselves at a level "above minimal requirements" according only to technicalfeasibility. It's a duty of Control Bodies (in Italy National Health Service's Work Environment Prevention Services) to verify the respect of law's preview minimal requirements. Quality standards and application guidelines, on the contrary, require collaboration and consensus among all actors involved in the implementation of health and safety managing systems on workplaces: Control Bodies, Professional Officers (Occupational Physicians, Safety Consultants), public and private Consultant Companies working on the field of health and safety at work. In this document some Emilia Romagna Region Control Bodies guidelines are discussed, and two experiences concerning public and private Consultant Companies are presented.

[Evidence-based medical surveillance in occupational health]

One of the major issues in Public Health is the effective allocation of resources to appropriate and efficient interventions. Medical surveillance is a part of the complex management of prevention in the Occupational Health and Safety field. The aim of the study is to present the efficacy and effectiveness of medical surveillance through an overview of articles and reviews (only one systematic review) found on scientific electronic databases (PubMed and Embase). Although the literature reports a lack of data, two main themes were selected and discussed: the quality of preventive actions and the cost-effectiveness of medical surveillance.

[Efficacy of periodic health surveillance of construction workers visited at the CPT of Bergamo]

The aim of this work is to expose the results obtained with the application of a model about efficacy in occupational medicine proposed by ALMLII. In particular we discuss the validity of some indicators of efficacy used in a large group of construction workers during health surveillance, in order to verify effectiveness and appropriateness of an occupational medicine service, as a part of the whole prevention and safety system.

[Effectiveness studies in the Italian Society of Occupational Medicine and Industrial Hygiene congresses (1989-2003)]

BACKGROUND

Knowledge of the results of studies on effectiveness of preventive interventions is a fundamental requirement in occupational medicine.

OBJECTIVES

The aim of this review was to identify Italian scientific production regarding this issue in the proceedings of the Italian Society of Occupational Medicine and Industrial Hygiene congresses over the last fifteen years.

METHODS

An initial selection of the communications on intervention effectiveness studies was performed on the basis of titles, aims, tables and figures of each single presentation. A further selection was made via full reading of the previously selected communications. The selected articles were classified by type of strategy discussed, production sector, study design and several other criteria.

RESULTS

108 studies were selected out of the 3215 papers (3.4%) published in the congress proceedings examined (1989-2003). More than half of these discussed technical control strategies. In the vast majority of cases, the study design was a pre- and post-evaluation of effectiveness, and the 6 (non-randomised) trials concerned vaccination programmes. Almost a quarter of the studies on accident prevention regarded the effectiveness of training programmes. Only 5 studies could be detected in Medline as articles later published in international journals.

CONCLUSIONS

On the basis of the Italian Society of Occupational Medicine congress proceedings over the last 15 years, the percentage of communications concerning effectiveness of preventive interventions in occupational health was 3.4%. Intervention effectiveness papers published in congress proceedings seem to reveal a quite unexpected production of effectiveness evaluation studies. Nonetheless, recommendations need to be made to improve study design and to promote effective prevention and control strategies.

Validation of performance indicators for rehabilitation of workers with mental health problems

OBJECTIVE

The objective of this study was to evaluate content validity and predictive validity of 11 performance indicators for the rehabilitation of workers with mental health problems.

RESEARCH DESIGN AND SUBJECTS

Content validity was assessed by experts who evaluated the validity of the performance indicators in 2 Delphi rounds. Predictive validity was evaluated by relating the performance indicators and their sum score to the outcome of a cohort of 191 employees absent from work as a result of mental health problems. Scores for the performance indicators were obtained by processing registration forms of consultations filled out by occupational physicians.

MAIN OUTCOME MEASURES

Three outcome measures were used: time to return to work, change in level of fatigue, and patient satisfaction.

RESULTS

Ten of the 11 performance indicators showed adequate content validity according to the expert panel. The evaluation of predictive validity yielded mixed results. One performance indicator did not show sufficient variability and was excluded from further analysis. The sum score of 9 performance indicators and performance on the evaluation of work disabilities were significantly related to a shorter time to return to work (hazard ratio [HR], respectively, 0.7; confidence interval [CI], 0.7-0.9 and 0.5; CI, 0.2-0.9). Adequate care regarding interventions aimed at providers of care in the curative sector was related to a longer time to return to work (HR, 1.8; CI, 1.1-3.0). The linear regression revealed that the sum score was not significantly related to a change in level of fatigue. However, lower quality of overall care was significantly related to moderately higher patient satisfaction (beta=0.18; P<0.05).

CONCLUSIONS

The evaluated performance indicators showed sufficient content validity and overall predictive validity, but no clear relation could be established between individual performance indicators and outcome.

[Limited change in the quality of the social medical guidance and in the satisfaction of sick-listed patients, after collaborative projects between general practitioners and occupational physicians]

OBJECTIVE

To evaluate whether regional projects for collaboration between general practitioners (GPs) and occupational physicians (OPs) improved the quality of their social medical guidance (SMG) and the satisfaction of their patients.

DESIGN

Evaluation study with before and after measurements with respect to the same GPs and OPs.

METHOD

Structured interviews were conducted with 58 GPs and 83 OPs regarding the SMG of their sick-listed patients. Before the project, the SMG of 1109 sick-listed patients was assessed and after the project, 1 or 1.5 years later, the SMG of 1121 sick-listed patients. These patients were sent a questionnaire by means of which their satisfaction could be assessed.

RESULTS

After the projects, the quality ofthe diagnosis by the OPs was improved and they also more often adhered to the official guidelines of the KNMG (Royal Netherlands Medical Association) when contacting the GP about a patient. The GPs more often contacted the OP if they needed more information about a patient after reaching a diagnosis. Nevertheless, in half to three-quarters of the patients for whom contact between GPs and OPs was indicated, this contact did not take place. There was no significant increase in patient satisfaction. Before the projects, patients gave their GP a grade of 8.2 on a 10-point scale and after the projects this was 8.5; the OPs were given a grade of 7.5 both times. Further analysis showed that there was no significant relation between the quality ofthe SMG and the patient's satisfaction with the doctor.

CONCLUSION

Although there was some improvement in the quality of the SMG, there was still insufficient cooperation between GPs and OPs compared to the guidelines. An increase in patient satisfaction was not demonstrated.

[Social medical guidance to achieve resumption of work: an outdated concept]

In the Netherlands there is a strict separation between the attending physician, i.e. the general practitioner, and the occupational physician. However, they are supposed to cooperate so that sick-listed patients will return to work earlier. It has now been demonstrated that this cooperation is far from sufficient and that all the expended effort has not led to an increase in patient satisfaction. It has to be admitted that the cooperation has failed. There is a strong need for adherence to guidelines, for quality audits and for scientific investigation in this sector.

[Ethical analysis of the decision-making process in occupational health practice]

BACKGROUND

Changes in workplaces and work organizations represent a challenge for governments, social partners and occupational health professionals whose aim is to appropriately satisfy emerging requirements and needs. An increasing number of occupational health problems requires a high-quality standard practice supported by ethically consistent decisions. The ethical aspect of the practice is strictly linked to that of appropriateness, involving requirements of effectiveness, efficiency and respect of ethical principles of the individual, community and society.

OBJECTIVES AND METHODS

The paper aims at focusing the ethical components of the quality of an occupational health program by taking a systematic approach to the ethical problems. The approach consists of a 2-step process. The first step consists of appraising the basic ethical principles of the dilemma ("to do good": to prevent or to remove evil and to do or to promote good; "not to do evil", implying not to inflict evil; to do no harm; autonomy implying respect of other's freedom and self-determination; justice implying equity, solidarity and non discrimination). The second step consists of detecting the stakeholders involved or interested in the decision. The alternatives are discussed according to the assessment of ethical costs (violating the consistentprinciple) and ethical benefits (fulfilment of the consistent principle) for the stakeholders.

RESULTS

Systematic analysis of the ethical components of the dilemma according to ethical principles and their discussion within a framework involving different stakeholders makes it possible to recognise ethical costs and ethical benefits of the alternative decisions. The decisions may have different costs and benefits, which should be considered and weighed to take a proper decision. Although there is no certainty about the suitability of the decision, the assessment of the ethical components may be a valuable tool in decision-making based on the awareness that any ethical aspect has been considered.

CONCLUSION

Occupational health professionals are requested to act with respect for general ethical principles and preferences of the individual, groups and setting. A high-quality practice will take into account the ethical content and the ethical conduct and any intervention will include analysis of ethical principles to compare alternative decisions and their consequences for the different stakeholders. This approach guarantees a practice based on, in addition to scientific evidence, the assessment of ethical costs and ethical benefits to favour decisions preventing conflicts.

Caution required when relying on a colleague's advice; a comparison between professional advice and evidence from the literature

Background

Occupational Physicians rely especially on advice from colleagues when answering their information demands. On the other hand, Evidence-based Medicine (EBM) promotes the use of up-to-date research literature instead of experts. To find out if there was a difference between expert-based practice and EBM we compared professional advice on occupational health topics with best evidence from the literature.

Methods

We asked 14 occupational physicians to consult their usual information sources on 12 pre-conceived occupational health problems. The problems were presented in the form of case vignettes which contained sufficient clinical information to be used by the occupational physicians for the consultation of their experts. We had searched the literature for the best available evidence on the 12 problems, which made it possible to answer the clinical questions with a clear yes or no.

Results

The cases could be used by the occupational physicians as arising from their own practice. All together the occupational physicians consulted 75 different experts. Almost half of the consulted experts were near colleagues, 10% were industrial hygienists, 8% medical specialists and the rest had a varied background. Fifty three percent (95% confidence interval 42% to 65%) of all professional advice was not in line with the research literature. In 18 cases (24%) professional advice explicitly referred to up-to-date research literature as their used source. These cases were substantially less incorrect (17%) than advice that had not mentioned the literature as a source (65%) (difference 48%, 95% Confidence Interval from 27% to 69%).

Conclusion

Advice that occupational physicians routinely get in their daily practice differs substantially from best evidence from the literature. Occupational physicians who ask professional advice should always ask about the evidence of this advice.

The Occupational Medicine agenda: routes and standards of specialization in Occupational Medicine in Europe

BACKGROUND

This paper reports on the nature of specialist training in occupational medicine (OM) in Europe from a survey of representatives from the Occupational Medicine section of the European Union of Medical Specialists/Union Européenne des Médecins Spécialistes (UEMS).

AIMS

To analyse current differences existing in the education and training requirements to become a specialist in OM in UEMS countries.

METHODS

Cross-sectional survey of representatives from 14 European countries.

RESULTS

While undergraduate training duration varied slightly, there is marked variation in postgraduate training for OM in UEMS countries. The countries surveyed outlined concerns for the funding of training, continuing professional development, research requirements and recruitment to the specialty.

CONCLUSION

There is a marked variation in postgraduate training in OM throughout UEMS countries. The variation between postgraduate training programmes is not consistent with UEMS charter requirements and because of national regulation purposes presents a barrier to the movement of migrant professionals within Europe. This study serves as a focus for further research into training routes and standards of specialization in OM in Europe.

Ill-health retirement: national rates and updated guidance for occupational physicians

BACKGROUND

Advising on ill-health retirement is an important role of most practising occupational physicians. In recent years, the eligibility criteria and process for gaining early retirement benefits have changed in many pension schemes in the UK.

AIM

To investigate the variation in rates of retirement due to ill-health in National Health Service (NHS) Trusts and Local Authorities and to update previously published guidance on ill-health retirement with specific reference to pension schemes with eligibility criteria that include permanence of incapacity due to ill-health.

METHODS

Rates of retirement were calculated for 222 NHS Trusts and 132 Local Authorities with more than 1500 employees. Literature searches and consensus statements by the authors.

RESULTS

Rates of retirement were widely distributed in the NHS Trusts and Local Authorities. The median rates of retirement were 2.11 (IQR 1.37-2.91)/1000 active members and 4.10 (IQR 3.01-6.10)/1000 employees, respectively (P<0.001). Difficulties in the doctor-patient relationship and in ascertaining the true functional ability of some patients were identified.

CONCLUSION

There continues to be marked variation in rates of early retirement due to ill-health within and between organizations that warrants further investigation. The general and specific guidance that appears as an appendix in Supplementary data to this paper should help occupational physicians to make equitable recommendations when assessing applications for early retirement benefits and fitness to work.

Occupational medicine: the case for reform

The specialty of occupational medicine is in peril, in large part because of its reliance on financing by industry, which has powerful incentives to limit costs and to favor physicians who are useful to their employers. Occupational physicians generally practice within the framework of the workers' compensation system. Serious flaws in the incentive structure of workers' compensation constrain objectivity in their practice. Under present law they are unavoidably subject to perverse influences from employers and insurance companies. A fundamental reform of workers' compensation law and practice is urgently needed to separate occupational physicians from the control of employers and workers' compensation insurers, whose interests should not be allowed to override the physicians' integrity or to compromise the specialty.

Changing medical criteria and medical severance payments may reduce the rate and costs of ill-health retirement

OBJECTIVES

To identify the core best practice standards in ill-health retirement (IHR) procedures. To investigate whether changing medical criteria and introducing medical severance payments affect the rate and cost of IHR.

METHODS

The core standards for best practice in IHR procedures were distilled from the published literature. On 1st April 2000 the study pension scheme altered the IHR medical criteria to define permanent incapacity and introduced medical severance payments for employees with temporary incapacity. Rates and costs of IHR were measured before and after these changes.

RESULTS

Following the changes, the annual rate of IHR fell from 8.89 to 2.90 per 1000 members (P < 0.001), the median age at IHR rose from 50 to 55 years (P = 0.01) and pension scheme costs fell by 25 million pounds sterlings per year.

CONCLUSIONS

Changing medical criteria and introducing medical severance payments may reduce the rate and costs of ill-health retirement. Target rates of four cases of IHR per 1000 active members per year, and 15% of total retirements, are proposed for schemes serving industries with average health risks.

Ill-health retirement at a health agency between 1991 and 1994

AIM

To describe factors related to the process of ill-health retirement (IHR) among employees of three hospital trusts.

METHODS

A descriptive study was carried out at a health agency on retirements recorded by the management due to ill-health between 1991 and 1994. Relevant data were extracted from records maintained in the occupational health department.

RESULTS

Among the 339 retirements recorded by the management as due to ill-health, 100 (29.5%) records could not be retrieved. Of the 239 records available for analysis, information regarding full- or part-time work was available for 164 (69%) employees. Further information from the individual's general practitioner or specialist was obtained for 106 (44%) employees and redeployment considered for 52 (22%) employees. The total number of employees who were recommended IHR was 125 (52%). One hundred and forty of the cases reported 220 disease conditions at pre-employment while 170 (71%) cases reported 229 disease conditions at retirement. In 37 (15.5%) the disease condition that led to retirement was the same as that at pre-employment. The commonest of these were musculoskeletal (46%; 17/37) and psychiatric (11%; 4/37) disorders. Twenty-one percent of all the retirements were due to work-related conditions. The time taken to arrive at the decision of IHR was more than 1 year for 20 (8%) employees.

CONCLUSIONS

This study found that many aspects of the IHR process did not meet the current suggested standards.

[Prophylaxis of occupational exposure to tuberculosis among physicians]

This article presents problems involved in the prevention of tuberculosis, which is essential in the practice of occupational medicine physicians. Tuberculosis prevention is an important issue since TB morbidity in Poland is relatively high compared with other European countries. The authors discuss TB risk factors among health care workers, epidemiology of tuberculosis as an occupational disease in European countries, including Poland, and the principles of medical prevention.

[Topics of occupational medicine and environment in codes and social accountability standards of business]

The problems of social accountability as applied to the occupational safety, health and environment are discussed. Russian and international codes and standards in the field are reviewed. Legal duties and rights of employers in occupational risk management for workers' health are considered. Some ethical aspects including health protection of female workers are discussed.

[Human resources and activities in the occupational medicine service of Poland in 2003]

BACKGROUND

The presented paper shows the most essential data concerning the state of human resources and activities of occupational medicine services in Poland in 2003.

MATERIALS AND METHODS

The reports (around 10 000) obtained from primary occupational medicine service units and regional occupational medicine centers (forms: MZ-35A and MZ-35) are the source of information about human resources and occupational medicine services activities.

RESULTS

A majority of regional centers, due to their restructuring, have approached the legal and organizational model described in the Occupational Medicine Service Act. The assessment of activities of primary occupational medicine centres units, performed by regional occupational medicine centers, indicates the need for constant training of physicians authorized to perform prophylactic examinations of employees.

CONCLUSIONS

The year 2003 did not witness any new significant changes in the structure of occupational medicine service. One can speak rather about the continuation of trends observed in previous years.

[Criteria for classification of upper limb work-related musculo-skeletal disorders due to biomechanical overload in occupational health. Consensus document by an Italian Working Group]

BACKGROUND AND OBJECTIVE

In a preliminary consensus document the authors proposed criteria and methods to identify upper limb work-related MSDs due to biomechanical overload. With this document they intend to define severity according to shared models and procedures so as to fit behaviours to diagnostic procedures and their medical-legal assessment. This becomes especially important in view of Ministerial Decree of April 27 2004 fixing the new lists of diseases having a possible work-related origin that must be reported by law in accordance with art. 139 of law n. 1124, and also on account of the impact of such diseases which, for the first time in Italy, are regulated by law.

CONTENTS

The working group, which included INAIL and ISPESL experts and was fully supported by SIMFER (Italian Society of Physical Medicine and Rehabilitation) and SINC (Italian Society of Clinical Neurophysiology), defined a general clinical procedure (anamnesis, objective examination and instrumental assessment) regarding each portion of the concerned upper limb (shoulder, elbow and wrist/hand). Once the presence and characteristics of anatomic and functional damages are established, the results allow a classification scheme to be proposed of upper limb diseases (tendon disorders and entrapment neuropathy) divided into 6 increasing severity stages: initial, medium, medium-severe, severe and extremely severe. Special attention was paid to two instrumental examinations that proved to be of great clinical interest, at least in occupational health: echography of soft tissues (in appendix) and electroneurography for entrapment neuropathy. The limitations of this proposal are discussed but the main goal was achieved: to standardize terms and provide homogeneous criteria to achieve classification of upper limb damage due to biomechanical overload for increasing severity levels. The working group research activity is part of a research project funded by ISPESL.

[Experts' opinion on criteria for certification of primary occupational medicine service units]

BACKGROUND

The article shows the results of a survey of the experts' opinions on the criteria for certification of primary occupational medicine service units.

MATERIALS AND METHODS

The group of experts surveyed comprised: the national consultant and regional consultants in occupational medicine, directors of regional occupational medicine centres, heads of organisation and supervision departments of those centres and chairmen of chapters of the Polish Association of Occupational Medicine. A questionnaire employed in the survey of the experts' opinions on the quality assessment criteria and indicators used in primary occupational medicine service units certification system were based on variables typical for management and quality assurance systems applied in health care. Of the 68 questionnaires sent, 45 of them were completed and returned.

RESULTS AND CONCLUSIONS

Among criteria for certification of primary occupational medicine service units, verified by experts, there were criteria common for management and quality assurance systems used in health care, e.g., client orientation; improvement of qualifications; using standards and medical procedures, quality book and medical documentation of self-control procedures; obligation to implement quality goals; information management, i.e. performance of cumulative analysis of documentation. Criteria used in quality management systems concerning organisation management, internal audits and human resources management do not apply to primary occupational medicine service units, because the majority of them are one-person enterprises acting as individual medical practices or physicians authorised to perform prophylactic examinations and acting as a primary occupational medicine service unit in the structure of public or non-public health care units. The survey revealed the presence of common criteria and indicators for services quality assessment in primary occupational medicine service units and other systems of management and health services quality assurance. Among them the following may be indicated: client-patient orientation (learning about his/her needs, regular assessment of satisfaction with services), improvement of personnel qualifications, information management, or constant improvement of services.

[Principles and criteria of occupational medicine standard in prevention of occupational deafness]

The article represents materials on prevention of occupational deafness--one of the most prevalent occupational entities.

Occupational medical history taking: how are today's physicians doing? A cross-sectional investigation of the frequency of occupational history taking by physicians in a major US teaching center

Occupational illness plays a prominent role in the health of society, yet physicians frequently neglect occupational history-taking both in clinical practice and in medical education. This study sought to examine the trends as well as related factors that influence the taking of occupationally related histories. A total of 2050 charts were reviewed for occupational information as well as several patient demographics. Physicians obtained gender and age histories in approximately 99% of their patients; however; they only completed an occupational history in 27.8%. Characteristics such as smoking, male gender, family cancer history, middle age, and medical (vs. surgical) admission were all correlated with obtaining an occupational history. Physicians continue to do a poor job of occupational history-taking and medical education must correct the situation.

Processes of care for individuals with work related asthma: treatment characteristics and impact of asthma on work

The prevalence of asthma among working adults continues to rise each year. The California Department of Health Services conducts surveillance of work related asthma (WRA) to classify each work related exposure using Doctor's First Reports of Occupational Illness and Injury (DFRs). Using a cross-sectional, descriptive, comparative design, additional interviews were conducted and medical records were reviewed to explore workers' and providers' perceptions of follow up care. Two cohorts were compared: workers with WRA who belonged to a large, single HMO (n = 79) and workers with WRA who underwent follow up outside this HMO (n = 76). The interview asked about providers seen, tests ordered, and the impact of asthma on work. The HMO clients were significantly more likely than the non-HMO clients to see occupational medicine specialists (p = .004) and have pulmonary function testing (p = .049) during initial treatment. Twenty-four percent of clients currently working reported missed workdays caused by asthma in the past 6 months. The findings indicate management of WRA varies by health care system in California.

Appraisal standards in occupational medicine

Following a series of serious misdemeanours by British doctors, the General Medical Council (GMC) has introduced a system of re-licensing called 'revalidation'. Annual medical appraisal forms an important cornerstone of the proposed system, but specific guidance is lacking on the content of appraisal for occupational physicians, and the kinds of evidence that they might bring to critical reviews of performance. Two educational bodies, the Revalidation Committee of the Faculty of Occupational Medicine, Royal College of Physicians and the Education Panel of the Society of Occupational Medicine, have jointly developed a set of recommendations on appraisal to further the process. In this paper we summarize the background and present the guidelines promulgated by the Faculty and the Society.

Evidence-based clinical occupational medicine: updating the ACOEM occupational medicine practice guidelines

In this article, we review the evolution and application of evidence based medicine and the results of the literature reviews and syntheses incorporated in the second edition of the guidelines. Our intent is to disseminate this information to practitioners treating injured workers and those managing and financing such care and disability management. Use of proven diagnostic, causality, testing,and treatment methods should markedly improve the quality of occupational medical care and make that care more cost effective.

[Estimate of uncertainty of measurements in clinical laboratories and in environmental, occupational, and preventive medicine]

According to recently issued (UNI CEI EN ISO/IEC 17025, UNI CEI ENV 13005 and prEN ISO 15189) standards, to assure the quality of analytical results and their comparability in time and in different places, testing and clinical laboratories must demonstrate to use validated methods, guarantee the traceability of their measurements and state the measurement uncertainty associated with each result. For some SI quantities, such as the mass, the traceability to SI and the estimate of measurement uncertainty are warranted by established methods. In the clinical laboratory and especially in preventive, environmental and occupational laboratory medicine, specific difficulties arise to warrant the traceability to the mole. On one hand, the whole concept of measurement uncertainty is new in laboratory medicine, on the other hand, its application faces practical difficulties, because of the wideness and the complexity of the analytical repertory, the lack of officially validated methods and matrix-specific reference materials traceable to SI. In this paper we discuss briefly the concept of measurement uncertainty and its meaning in comparison with other parameters used to define the performance of analytical methods. In addition, we describe the procedures recommended by international organisations for estimating measurement uncertainty and interpreting analytical results with an associated measurement uncertainty in comparison with limit values.

Reliability of sickness certificates in detecting potential sick leave reduction by modifying working conditions: a clinical epidemiology study

BACKGROUND

Medical sickness certificates are generally the main source for information when scrutinizing the need for aimed intervention strategies to avoid or reduce the individual and community side effects of sick leave. This study explored the value of medical sickness certificates related to daily work in Norwegian National Insurance Offices to identify sick-listed persons, where modified working conditions might reduce the ongoing sick leave.

METHODS

The potential for reducing the ongoing sick leave by modifying working conditions was individually assessed on routine sickness certificates in 999 consecutive sick leave episodes by four Norwegian National Insurance collaborators, two with and two without formal medical competence. The study took place in Northern Norway in 1997 and 1998. Agreement analysed with differences against mean, kappa, and proportional-agreement analysis within and between groups of assessors was used in the judgement. Agreements between the assessors and the self-assessment of sick-listed subjects were additionally analysed in 159 sick-leave episodes.

RESULTS

Both sick-listed subjects and National Insurance collaborators anticipated a potential reduction in sick leave in 20-30% of cases, and in another 20% the potential was assessed as possible. The chance corrected agreements, however, were poor (k < 0.20) within and between groups of National Insurance collaborators. The agreement between National Insurance collaborators and the sick-listed subjects was no better than chance. Neither extended medical information nor formal medical competence increased agreement in cases where modified working conditions might have reduced sick leave.

CONCLUSION

Information in medical sickness certificates proved ineffective in detecting cases where modified working conditions may reduce sick leave, and focusing on medical certificates may prevent identification of needed interventions. Strategies on how to communicate directly with sick-listed subjects would enable social authorities to exploit more of the sick leave reduction potential by modifying the working conditions than strategies on improving medical information.

Medical and trauma evacuations

Evacuating ill or injured expatriates on international assignments from globally challenging locations is a potent source of concern for individuals who are involved before, during, and after overseas assignments. It is essential to minimize the risk for such evacuations and to make the evacuations proceed as smoothly and safely as possible. The first half of this article addresses the planning and processes that are required to make inevitable medical evacuations as safe and smooth as possible. The second half reviews the non-medical consequences that medical and security evacuations can have for employees, dependents, and employers.

[Recent concept of protection of workers and general population against electromagnetic fields in the European countries]

In 1994, guidelines for protection against EM fields were elaborated by the International Commission for Non-Ionizing Radiation Protection (ICNIRP). In 1998, they were slightly modified and became the base for the 1999 recommendation of the UE Commission. The ICNIRP recommendations are based on few selected criteria, and thus provide good protection in the case of short-term exposures to EM fields, but possible effects of EM fields at intensities lower than those admissible by the ICNIPR standards raise still growing doubts. Over a couple of years, well educated and organized groups of citizens and non-governmental organizations call attention to risks of long-term exposure of humans to weak EM fields. In their reviews, the members of these groups/organizations draw attention to the need for a precautionary approach on the one hand, and postulate better protection of the general population and workers from weak EM fields on the other. The evaluation of the present situation indicates that the range of the influence of independent groups/organizations supporting the modification of ICNIPR guidelines to include the effects of low-level EM fields is steadily growing.

[Polish guidelines of 2001 for maximum admissible intensities in high frequency EMF versus European Union recommendations]

In 1999, a draft of amendments to maximum admissible intensities (MAI) of electromagnetic fields (0 Hz-300 GHz) was prepared by Professor H. Korniewicz of the Central Institute for Labour Protection, Warsaw, in cooperation with the Nofer Institute of Occupational Medicine, Łódź (radio- and microwaves) and the Military Institute of Hygiene and Epidemiology, Warsaw (pulse radiation). Before 2000, the development of the national MAI guidelines for the frequency range of 0.1 MHz-300 GHz was based on the knowledge of biological and health effects of EMF exposure available on the turn of the 1960s. A current basis for establishing the MAI international standards is a well-documented thermal effect measured by the value of a specific absorption rate (SAR), whereas the effects of resonant absorption imposes the nature of the functional dependency on EMF frequency. The Russian standards, already thoroughly analyzed, still take so-called non-thermal effects and the conception of energetic load for a work-shift with its progressive averaging (see hazardous zone in Polish guidelines) as a basis for setting maximum admissible intensities. The World Health Organization recommends a harmonization of the EMF protection guidelines, existing in different countries, with the guidelines of the International Commission for Non-Ionizing Radiation Protection (ICNIRP), and its position is supported by the European Union.

[Cost analysis of task implementation at the regional occupational medicine centers]

In this paper, the considerations on setting the costs of the tasks to be implemented by provincial occupational medicine centers (POMCs) are continued (Med Pr 2001; 3: 197-201). Under the research project carried out by the Nofer Institute of Occupational Medicine, the method of setting costs has been elaborated and implemented in selected POMCs. At the implementation stage, a set of forms to collect and process data on costs involved was prepared. These forms together with the instruction were distributed among the selected centers. The data collected were analyzed, and the conclusions concerning the factors responsible for shaping relevant costs in POMCs, as well as the barriers hindering the implementation of this new method were formulated. The introduction of new principles of isolating so called "cost phases" was necessary only for setting full costs of health promotion and postgraduate education programs. The method of setting values for the remaining POMC costs has been implemented without its modification. The collected data on costs show that the wages of physicians and medium-level personnel affects mostly the costs of tasks in a given center, however, indirect costs also have a substantial share in unit costs. In addition, the range of specialistic consultations and diagnostic tests performed in or outside POMCs also exert some effect on the differentiation of unit costs.

[Polish regulations on maximum admissible intensities for electric and magnetic frequencies of 60 Hz and the European Union recommendations for electrical power engineering]

Electric and magnetic fields of 50 Hz from electric power devices affect not only workers, but also the general population, as these devices are also located in populated areas, hence the duality of regulations on maximum admissible intensities. This paper presents these regulations and discusses in detail the changes of 2001. Based on the Polish regulations, hygienic evaluation of electric power devices has been attempted. The Polish regulations on the 50 Hz electromagnetic fields were compared with relevant international regulations of CENELEC and the European Union recommendations. Our maximum admissible intensities have been found to conform with the international standards.

Negative and non-positive epidemiological studies

The aim of this study was to identify and discuss validity aspects on so called negative and non-positive studies. Arguments and examples are drawn from experiences in occupational health epidemiology regarding the interpretation of more or less equivocal study results. A negative study may be defined as showing a result that goes against the investigated hypothesis of an increased (or prevented) risk. Traditionally, studies with a risk estimate (relative risk or odds ratio) above, but close to unity are also referred to as negative, given a narrow confidence interval (CI) that includes unity. A risk estimate above unity with the CI including unity is non-positive, however, but an estimate below unity with upper CI bond exceeding unity might be seen as possibly negative or non-negative. A weaker "significance" than usually required should perhaps be accepted when evaluating serious hazards. In contrast to positive studies, the negative and non-positive studies tend to escape criticism in spite of questionable validity that may have obscured existing risks (or preventive effects). Even stronger arguments can be made in criticising negative and non-positive studies than positive studies, for example, regarding selection phenomena, and observational problems regarding exposure and outcome. Negative confounding should be considered although usually weak. In case-control studies, so called over-matching may obscure an existing risk as could the "healthy worker effect" in cohort studies. Small scale non-positive studies should be made available for meta-analyses and when considering studies that do not convincingly show a risk; those who are exposed should be given the "benefit of the doubt".