HEART DISEASE UNDER WORKMEN'S COMPENSATION

In expert testimony before the Industrial Accident Commission, all physicians are taken as equally competent. The value of their testimony depends upon the validity of their data and the reasons for the conclusions drawn. In case of conflicting opinion, the referees, who are laymen, must decide on the basis of the testimony. Therefore physicians preparing reports must see that data are complete, that all routine investigative procedures are not only applied but reported, and that the reasons for claiming connection of injury with employment are fully stated. Moreover, other recognized causes of the patient''s condition should be considered and ruled out for reasons given.The increasing number of claims for workmen''s compensation in heart disease, and the increasing tendency of insurers to settle rather than contest claims, may actually be harmful to the welfare of persons with heart disease, for it deters employers from hiring them and thus risking higher insurance costs. Physicians concerned with compensation claims must develop more widely acceptable standards that properly separate the inherent risk of heart disease from that incurred through employment for which the employer may reasonably be considered liable.     

Costs and Cost-Effectiveness of a Mobile Phone Text-Message Reminder Programmes to Improve Health Workers' Adherence to Malaria Guidelines in Kenya

Background

Simple interventions for improving health workers'' adherence to malaria case-management guidelines are urgently required across Africa. A recent trial in Kenya showed that text-message reminders sent to health workers'' mobile phones improved management of pediatric outpatients by 25 percentage points. In this paper we examine costs and cost-effectiveness of this intervention.

Methods/Findings

We evaluate costs and cost-effectiveness in 2010 USD under three implementation scenarios: (1) as implemented under study conditions in study areas; (2) if the intervention was routinely implemented by the Ministry of Health (MoH) in the same areas; and (3) if the intervention was scaled up nationally. Under study conditions, intervention costs were 19,342 USD, of which 45% were for developing and pretesting text-messages, 12% for developing text-message distribution system, 29% for collecting health workers'' phone numbers, and 13% were costs of sending text-messages and monitoring of the system. If the intervention was implemented in the same areas by the MoH, the costs would be 28% lower (13,920 USD) due to lower costs of collecting health workers'' numbers. The cost of national scale-up would be 97,350 USD, and the majority of these costs (66%) would be for sending text-messages. The cost per additional child correctly managed was 0.50 USD under study conditions, 0.36 USD if implemented by the MoH in the same area, and estimated at only 0.03 USD if implemented nationally. Even if the effect size was only 5% or the cost on the national scale was 400% higher than estimated, the cost per additional child correctly managed would be only 0.16 USD.

Conclusions

A simple text-messaging intervention improving health worker adherence to malaria guidelines is effective and inexpensive. Further research is justified to optimize delivery of the intervention and expand targets beyond children and malaria disease.     

ATTITUDES TOWARD THE DUBIOUS COMPENSATION CLAIM

Laws providing for compensation of workmen for occupational injury are a powerful socio-economic force.In settlement of compensation claims the goal, difficult to achieve, is fairness to employee, employer and insurance carrier. Often, medical, legal, economic and social considerations conflict with one another. A “fact” in one field may not be considered so in another.Since medical data and testimony often guide the ultimate decision of a compensation claim, the physician''s attitude is a large factor not only immediately and directly in determination of the case at hand but, perhaps more important, in the ultimate direction of the socio-economic forces which spring from the sum of all such determinations.To perpetuate the good in workmen''s compensation laws, the next generation of physicians—and of lawyers and business administrators as well, for they, too, are involved—ought to have basic training in the social sciences in order that they may have a broad rather than a segmental view of the problems with which they deal.     

Upper limb joint angle measurement in occupational health

Usual human motion capture systems are designed to work in controlled laboratory conditions. For occupational health, instruments that can measure during normal daily life are essential, as the evaluation of the workers' movements is a key factor to reduce employee injury- and illness-related costs. In this paper, we present a method for joint angle measurement, combining inertial sensors (accelerometers and gyroscopes) and magnetic sensors. This method estimates wrist flexion, wrist lateral deviation, elbow flexion, elbow pronation, shoulder flexion, shoulder abduction and shoulder internal rotation. The algorithms avoid numerical integration of the signals, which allows for long-time estimations without angle estimation drift. The system has been tested both under laboratory and field conditions. Controlled laboratory tests show mean estimation errors between 0.06° and of 1.05°, and standard deviation between 2.18° and 9.20°. Field tests seem to confirm these results when no ferromagnetic materials are close to the measurement system.     

HIV Treatment as Prevention: Issues in Economic Evaluation

Meyer-Rath and Over assert in another article in the July 2012 PLoS Medicine Collection, “Investigating the Impact of Treatment on New HIV Infections”, that economic evaluations of antiretroviral therapy (ART) in currently existing programs and in HIV treatment as prevention (TasP) programs should use cost functions that capture cost dependence on a number of factors, such as scale and scope of delivery, health states, ART regimens, health workers'' experience, patients'' time on treatment, and the distribution of delivery across public and private sectors. We argue that for particular evaluation purposes (e.g., to establish the social value of TasP) and from particular perspectives (e.g., national health policy makers) less detailed cost functions may be sufficient. We then extend the discussion of economic evaluation of TasP, describing why ART outcomes and costs assessed in currently existing programs are unlikely to be generalizable to TasP programs for several fundamental reasons. First, to achieve frequent, widespread HIV testing and high uptake of ART immediately following an HIV diagnosis, TasP programs will require components that are not present in current ART programs and whose costs are not included in current estimates. Second, the early initiation of ART under TasP will change not only patients'' disease courses and treatment experiences—which can affect behaviors that determine clinical treatment success, such as ART adherence and retention—but also quality of life and economic outcomes for HIV-infected individuals. Third, the preventive effects of TasP are likely to alter the composition of the HIV-infected population over time, changing its biological and behavioral characteristics and leading to different costs and outcomes for ART.     

Preventing disability from work-related low-back pain. New evidence gives new hope -- if we can just get all the players onside

Despite the publication in the mid-1990s of comprehensive practice guidelines for the management of acute low-back pain, both in the United States and elsewhere, this ubiquitous health problem continues to be the main cause of workers'' compensation claims in much of the Western world. This paper represents a synthesis of the intervention studies published in the last 4 years and is based on a new approach to categorizing these studies that emphasizes the stage or phase of back pain at the time of intervention and the site or agent of the intervention. Current thinking suggests that medical management in the first 3-4 weeks after the onset of pain should be generally conservative. Several studies of rather heterogeneous interventions focusing on return to work and implemented in the subacute stage (3-4 to 12 weeks after the onset of pain) have shown important reductions in time lost from work (by 30% to 50%). There is substantial evidence indicating that employers who promptly offer appropriately modified duties can reduce time lost per episode of back pain by at least 30%, with frequent spin-off effects on the incidence of new back-pain claims as well. Finally, newer studies of guidelines-based approaches to back pain in the workplace suggest that a combination of all these approaches, in a coordinated workplace-linked care system, can achieve a reduction of 50% in time lost due to back pain, at no extra cost and, in some settings, with significant savings.     

TRAUMA OR STRAIN AND HEART DISEASE—Causal Relationship

Myocardial infarction and coronary insufficiency are the common conditions involved in workmen''s compensation cases based on allegations of cardiac injury. Since coronary disease tends to be a progressive process, punctuated by sudden accidents, it is difficult to determine when a given stress at work may have had a significant effect in producing an infarction. Though there are gaps in our knowledge, considerable information is available indicating the way in which effort or stress may produce a myocardial infarction.Certain states have taken steps to develop more uniformity of medical opinion regarding causal relationship of stress to heart disease, and in other ways have attempted to improve the application of workmen''s compensation laws in an attempt to provide fair and prompt compensation to those injured by their work but to discourage abuses of these laws.     

High Rate of Awarding Compensation for Claims of Injuries Related to Clinical Trials by Pharmaceutical Companies in Japan: A Questionnaire Survey

Introduction

International norms and ethical standards have suggested that compensation for research-related injury should be provided to injured research volunteers. However, statistical data of incidence of compensation claims and the rate of awarding them have been rarely reported.

Method

Questionnaire surveys were sent to pharmaceutical companies and medical institutions, focusing on industry-initiated clinical trials aiming at new drug applications (NDAs) on patient volunteers in Japan.

Results

With the answers from pharmaceutical companies, the incidence of compensation was 0.8%, including 0.06% of monetary compensation. Of the cases of compensation claims, 99% were awarded. In turn, with the answers from medical institutions, the incidence of compensation was 0.6%, including 0.4% of serious but not death cases, and 0.04% of death cases. Furthermore, most claims for compensation were initiated by medical institutions, rather than by the patients. On the other hand, with the answers from clinical trial volunteers, 3% of respondents received compensations. These compensated cases were 25% of the injuries which cannot be ruled out from the scope of compensation.

Conclusion

Our study results demonstrated that Japanese pharmaceutical companies have provided a high rate of compensation for clinical trial-related injuries despite the possibility of overestimation. In the era of global clinical development, our study indicates the importance of further surveys to find each country''s compensation policy by determining how it is being implemented based on a survey of the actual status of compensation coming from statistical data.     

Gauging U.S. Emergency Medical Services Workers' Willingness to Respond to Pandemic Influenza Using a Threat- and Efficacy-Based Assessment Framework

Background

Emergency Medical Services workers'' willingness to report to duty in an influenza pandemic is essential to healthcare system surge amidst a global threat. Application of Witte''s Extended Parallel Process Model (EPPM) has shown utility for revealing influences of perceived threat and efficacy on non-EMS public health providers'' willingness to respond in an influenza pandemic. We thus propose using an EPPM-informed assessment of EMS workers'' perspectives toward fulfilling their influenza pandemic response roles.

Methodology/Principal Findings

We administered an EPPM-informed snapshot survey about attitudes and beliefs toward pandemic influenza response, to a nationally representative, stratified random sample of 1,537 U.S. EMS workers from May–June 2009 (overall response rate: 49%). Of the 586 respondents who met inclusion criteria (currently active EMS providers in primarily EMS response roles), 12% indicated they would not voluntarily report to duty in a pandemic influenza emergency if asked, 7% if required. A majority (52%) indicated their unwillingness to report to work if risk of disease transmission to family existed. Confidence in personal safety at work (OR = 3.3) and a high threat/high efficacy (“concerned and confident”) EPPM profile (OR = 4.7) distinguished those who were more likely to voluntarily report to duty. Although 96% of EMS workers indicated that they would probably or definitely report to work if they were guaranteed a pandemic influenza vaccine, only 59% had received an influenza immunization in the preceding 12 months.

Conclusions/Significance

EMS workers'' response willingness gaps pose a substantial challenge to prehospital surge capacity in an influenza pandemic. “Concerned and confident” EMS workers are more than four times as likely to fulfill pandemic influenza response expectations. Confidence in workplace safety is a positively influential modifier of their response willingness. These findings can inform insights into interventions for enhancing EMS workers'' willingness to respond in the face of a global infectious disease threat.     

An outbreak of illness among aerospace workers.

A multispecialty panel of physicians evaluated a case series of 53 composite-materials workers in a large aircraft manufacturing facility who filed workers'' compensation claims for illness labeled by the media as the "aerospace syndrome." Possible skin and respiratory tract exposures included formaldehyde, phenol, particulates, epoxy resins, and trace organic solvents, but measured concentrations were well below all regulatory and consensus standards. Most workers had histories of transient skin or respiratory tract irritation consistent with the known potential toxicity of these materials. None of the workers tested had immunoglobulin IgG or IgE antibodies to human serum albumin complexed with formaldehyde. A majority (74%) met DSM-III-R [Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised] criteria for major depression, panic disorder, or both. Most of these psychiatric disorders were of a recent onset, correlating in time with the use of phenol- and formaldehyde-impregnated composite material. Psychosocial factors were thought to have played a major role in the high prevalence of illness in this group and should be evaluated directly in well-controlled epidemiologic studies of similar crisis-building situations in the future.     

The Physician and Workmen's Compensation—A New Paramedic to Help with Compensation Cases

The first social, no-fault, insurance legislation in California was the Workmen''s Compensation Act of 1911. It has been changed and modified in the years since, and is having an increasing impact on the practice of most California physicians. Many physicians consider caring for the occupationally ill or injured time-consuming and difficult. A newly emerging kind of paramedic, the workmen''s compensation benefit administrator, is available to assist the physician in overcoming difficulties encountered. A cooperative effort between the physician and the benefit administrator will expedite management of industrial patients.     

Privileged Communications—The Effect of California's New Evidence Code As It Concerns Physicians and Psychotherapists

A physician has an ethical duty to hold in confidence communications made to him by his patient. A legal recognition of this ethical duty is found in the concept of privilege, which is the subject of this article. January 1967 will bring to California physicians a new protection for patients'' communications. The physician-patient privilege has been redefined to include confidential communications made during diagnostic evaluation, those made to non-licensed physicians, interns and medical aides, and those overheard by eavesdroppers. There has been added a psychotherapist-patient privilege designed to facilitate communications required in psychotherapy as well as in behavioral research.This paper first presents a brief historical background and discusses the protections and limitations afforded by the new California Evidence Code. There follows a section on the psychotherapist-patient privilege with the recommendation that in the context of psychotherapy, patients of physicians who are not psychiatrists should be afforded the additional benefits of the psychotherapist-patient privilege. Lastly, advice is given concerning the physician''s conduct in relation to his duty to claim privilege under the new code.     

无居民海岛开发生态损害评估——以象山县大羊屿岛为例

无居民海岛独特的生态系统和地理位置决定了受损后的修复成本极高、开发难度极大,其保护与开发已经成为国内外学界关注的重点。基于海岛生态系统服务价值理论构建了无居民海岛开发的生态损害评估模型,以我国首个公开拍卖使用权的大羊屿岛为例验证模型的科学性和可行性,并与2018年调整后的无居民海岛使用金征收标准中生态损害成本额度进行对比分析。研究结果表明：（1）大羊屿岛开发的生态损害补偿金为1644.82万元。其中,陆域开发行为所需的生态损害补偿金为890.19万元,高于海洋开发行为所造成的生态损害补偿金;（2）通过本文计算的海岛陆域生态损害补偿金高出现行海岛使用金标准中的生态损害成本371.90万元,2018年旅游用岛使用金征收标准仍有上调空间。对无居民海岛开发的生态损害评估可以增强政府和企业对于海岛资源的保护意识,重新权衡无居民海岛开发的利弊,避免对海岛资源过度和盲目的开发。     

QUESTIONABLE COMPENSATION CLAIMS—Principles of Special Examination

In deciding a disputed claim of disability arising from occupation, physicians should ascertain whether a patient''s medical history has any bearing on the disability; they should attempt psychologic evaluation of the patient as it may reflect on the conditions they observe in physical examination; they should investigate symptoms complained of by the patient rather than accept them as prima facie evidence of disability; and they must have knowledge of the extent to which an injury can cause disability.It is urged that standards of physical ability and disability, as well as of other physical factors which may affect compensation claims, be established by organized research.     

Weekly iron-folic acid supplementation with regular deworming is cost-effective in preventing anaemia in women of reproductive age in Vietnam

Background

To estimate the cost and cost-effectiveness of a project administering de-worming and weekly iron-folic acid supplementation to control anaemia in women of reproductive age in Yen Bai province, Vietnam.

Methods and Findings

Cost effectiveness was evaluated using data on programmatic costs based on two surveys in 2006 and 2009 and impact on anaemia and iron status collected in 2006, 2007, and 2008. Data on initial costs for training and educational materials were obtained from the records of the National Institute of Malariology, Parasitology and Entomology and the Yen Bai Malaria Control Program. Structured questionnaires for health workers at district, commune and village level were used to collect ongoing distribution and monitoring costs, and for participants to collect transport and loss of earnings costs. The cost per woman treated (defined as consuming at least 75% of the recommended intake) was USD0.76 per annum. This estimate includes financial costs (for supplies, training), and costs of health care workers'' time. Prevalence of anaemia fell from 38% at baseline, to 20% after 12 months. Thus, the cost-effectiveness of the project is assessed at USD 4.24 per anaemia case prevented per year. Based on estimated productivity gains for adult women, the benefit:cost ratio is 6.7∶1. Cost of the supplements and anthelminthics was 47% of the total, while costs of training, monitoring, and health workers'' time accounted for 53%.

Conclusion

The study shows that weekly iron-folic acid supplementation and regular de-worming is a low-cost and cost-effective intervention and would be appropriate for population-based introduction in settings with a high prevalence of anaemia and iron deficiency and low malaria infection rates.     

Occupational cancer: experience in Ontario.

This paper reviews the experience of the Workmen''s Compensation Board of Ontario in identifying cases of cancer that could be attributed to occupational hazards. Worker''s claims for compensation are allowed if there is reasonable medical evidence that their cancer was caused by exposure to risk factors associated with their occupation. Details of the types of cancer associated with specific carcinogens or fields of employment are discussed. About 50% of the cases were related to exposure in particular industrial operations that functioned for relatively brief periods. The number of deaths from cancer identified as being caused by occupational factors is compared with the total for cancer from all causes in Ontario during the period 1971 through 1975. Although all workers eligible for compensation may not have been identified, the data suggest that less than 1% of cancer is presently caused by occupational factors.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

Access to reliable information about long-term prognosis influences clinical opinion on use of lifesaving intervention

Background

Decompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers'' opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI.

Method

A two-part structured interview was used to assess the participants'' opinion to perform decompressive craniectomy for three patients who had very severe TBI. Their opinion was assessed before and after knowing the predicted and observed risks of an unfavourable long-term neurological outcome in various scenarios.

Results

Five hundred healthcare workers with a wide variety of clinical backgrounds participated. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves (mean difference in visual analogue scale [VAS] −1.5, 95% confidence interval −1.3 to −1.6), especially when the next of kin of the patients requested intervention. Patients'' preferences were more similar to patients who had advance directives. The participants'' preferences to perform the procedure for themselves and their patients both significantly reduced after knowing the predicted risks of unfavourable outcomes, and the changes in attitude were consistent across different specialties, amount of experience in caring for similar patients, religious backgrounds, and positions in the specialty of the participants.

Conclusions

Access to objective information on risk of an unfavourable long-term outcome influenced healthcare workers'' decision to recommend decompressive craniectomy, considered as a lifesaving procedure, for patients with very severe TBI.     

Plastic surgery-important advances in clinical medicine: collagen

Workers'' compensation laws influence recovery from injury. They affect the “cause” of disease, access to care, diagnostic evaluation, treatment, response to treatment and residual disability. Paradoxically, financial compensation may discourage return to work, the appeal process may increase disability, an open claim may inhibit return to work and recovering patients may be unable to return to work.Physicians may help improve the prospects of returning patients to work by providing care that is medical, caring and independent. It is essential that the treatment of back pain be based on the known natural history and on the understanding that the management of acute pain differs from that of chronic pain.Increased awareness of the factors controlling return to work should motivate legislative bodies, labor and industry to alter those features of the compensation system that interfere with the return to work of injured workers.