Differential reporting of work-related mental ill-health in doctors.

BACKGROUND: Evidence suggests that the medical profession is reluctant to report mental ill-health despite its high prevalence. AIMS: To compare differential reporting patterns in the incidence of work-related mental ill-health (WRMIH) affecting doctors with selected comparison occupational groups, as determined by surveillance by general practitioners (GPs), specialist psychiatrists and occupational physicians (OPs). METHODS: New cases of medically reported WRMIH were reported prospectively between 2006 and 2009 by GPs, psychiatrists and OPs as part of The Health and Occupation Research (THOR) network. For GP and psychiatry reporting schemes, incidence rates (IRs) for doctors, nurses, teachers, corporate managers and protective service workers were calculated using information from the Labour Force Survey as the denominator. In OP surveys, participating reporters provided denominator information to calculate IRs for doctors, nurses and teachers. RESULTS: Average annual IRs expressed per 100000 person/years employed as reported by GPs, psychiatrists and OPs, respectively, were: doctors (309, 971, 430), nurses (891, 208, 670), teachers (1040, 136, 210) and for GPs and psychiatrists, respectively, were: protective service workers (1432, 721) and corporate managers (428, 90). Psychiatrists reported a higher incidence of WRMIH in doctors, whereas GPs reported higher incidences of WRMIH in other occupations (chi-squared test, P < 0.001). CONCLUSIONS: The distribution of the incidence of new cases reported across different schemes suggests a differential reporting pattern of WRMIH in doctors. The higher IR for doctors in psychiatrist-reported WRMIH could be due to factors such as disease severity and bypassing formal referral channels.

EELAB: an innovative educational resource in occupational medicine.

BACKGROUND: Postgraduate education, training and clinical governance in occupational medicine (OM) require easily accessible yet rigorous, research and evidence-based tools based on actual clinical practice. AIMS: To develop and evaluate an online resource helping physicians develop their OM skills using their own cases of work-related ill-health (WRIH). METHODS: WRIH data reported by general practitioners (GPs) to The Health and Occupation Research (THOR) network were used to identify common OM clinical problems, their reported causes and management. Searches were undertaken for corresponding evidence-based and audit guidelines. A web portal entitled Electronic, Experiential, Learning, Audit and Benchmarking (EELAB) was designed to enable access to interactive resources preferably by entering data about actual cases. EELAB offered disease-specific online learning and self-assessment, self-audit of clinical management against external standards and benchmarking against their peers' practices as recorded in the research database. The resource was made available to 250 GPs and 224 occupational physicians in UK as well as postgraduate OM students for evaluation. RESULTS: Feedback was generally very favourable with physicians reporting their EELAB use for case-based assignments. Comments such as those suggesting a wider range of clinical conditions have guided further improvement. External peer-reviewed evaluation resulted in accreditation by the Royal College of GPs and by the Faculties of OM (FOM) of London and of Ireland. CONCLUSIONS: This innovative resource has been shown to achieve education, self-audit and benchmarking objectives, based on the participants' clinical practice and an extensive research database.

Reporting and prediction of work-related sickness absence by general practitioners.

BACKGROUND: Information on sickness absence (SA) duration in general practice is difficult to record. The duration of absence certified by general practitioners (GPs) can be viewed as a prognosis for return to work. The Health and Occupation Research network in General Practice (THOR-GP) collects SA information from GPs associated with cases of work-related ill-health. A sample of these cases is followed up 1 year retrospectively to gather information on the duration of absence. AIMS: To examine the extent of the underestimation of SA in routinely reported data and to investigate how well GPs predict patients' return to work. METHODS: THOR-GPs submit case and SA information using a web-based form. GPs who submitted selected cases were asked about the total number of days of SA and whether the patient had returned to work. RESULTS: THOR-GPs' routine SA data collection underestimated absence duration by 61%. According to the retrospective data, a much larger proportion of periods of absence due to work-related mental ill-health developed into long-term SA (60%) than episodes attributed to musculoskeletal disorders (32%). In over half the reported cases, the return to work was longer than the GP initially predicted. CONCLUSIONS: THOR-GP prospectively reported SA data underestimated the total length of absence; however, these data can examine the episodic rates of absence within different groups. More accurate longitudinal data can be collected retrospectively. GPs' ability to predict the length of time a patient will be away from work is important to enable treatment and rehabilitation planning in order to decrease the likelihood of a patient falling into long-term SA.

The utility of information collected by occupational disease surveillance systems.

BACKGROUND: The Health and Occupation Research (THOR) network in the UK and the Republic of Ireland (ROI) is an integrated system of surveillance schemes collecting work-related ill-health (WRIH) data since 1989. In addition to providing information about disease incidence, trends in incidence and the identification of new hazards, THOR also operates an ad hoc data enquiry service enabling interested parties to request information about cases of WRIH reported to THOR. AIMS: To examine requests for information made to a network of surveillance schemes for WRIH in the UK. METHODS: Analysis via SPSS of data requests received by THOR between 2002 and 2014. RESULTS: A total of 631 requests were received by THOR between 2002 and 2014. Requests were predominantly submitted by participating THOR physicians (34%) and the main THOR funder-the UK Health & Safety Executive (HSE) (31%). The majority (67%) of requests were for information about work-related respiratory or skin disease with relatively few requests for other diagnoses, such as musculoskeletal or mental ill-health. Requests frequently related to a specific industry and/or occupation (42%) and/or a specific causal agent (58%). CONCLUSIONS: Data collected by occupational disease surveillance systems such as THOR are an extremely useful source of information, the use of which extends beyond informing government on disease incidence and trends in incidence. The data collected provide a framework that can assist a wide range of enquirers with clinical diagnoses, identification of suspected causative agents/exposures and to highlight growing risks in particular industrial and occupational sectors.

Workplace injury data reported by occupational physicians and general practitioners.

BACKGROUND: Accurate workplace injury data are useful in the prioritization of prevention strategies. In the UK, physicians report workplace ill-health data within The Health and Occupation Research (THOR) network, including injury case reports. AIMS: To compare workplace injury data reported by occupational physicians (OPs) and general practitioners (GPs) to THOR. METHODS: Injury cases reported by OPs and GPs, reported to THOR between 2006 and 2012 were analysed. Demographics, industrial groups, nature of injury, kind of accident and site of injury were compared. Data on sickness absence for workplace injuries reported by GPs were investigated. RESULTS: In total, 2017 workplace injury cases were reported by OPs and GPs. Males were more likely to sustain a workplace accident than females. Sprains and strains were reported most often, with the upper limbs being affected most frequently. Slips, trips and falls were identified as important causal factors by both OPs and GPs. Psychological injuries also featured in THOR reporting, with a higher proportion reported by OPs (21%) than by GPs (3%). The proportion of people classified as 'unfit' by GPs reduced following the introduction of the 'fit' note. CONCLUSIONS: THOR reports returned by OPs and GPs provide a valuable source of information of workplace injury data, and complement other sources of information, such as the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations and the Labour Force Survey.

Has the fit note reduced general practice sickness certification rates?

BACKGROUND: In 2010, the fit note replaced the sick note to help focus on what people are capable of doing, rather than signing patients 'off sick'. AIMS: To compare proportions of work-related ill-health issued with sickness certification pre- and post-fit note introduction and assess sickness absence trends. METHODS: General practitioners (GPs) report data on work-related ill-health and sickness absence via The Health and Occupation Research network in General Practice. The proportion of cases issued with sickness certification 4 years before and 3 years after the fit note introduction were compared. Changes in certification incidence rate ratios were measured over time. RESULTS: Participating GPs reported 5517 cases of work-related ill-health. Pre-fit note introduction 50% of cases were certified sick. There was no change in the proportion of cases certified sick in the first year post-fit note, despite 13% of cases classified as 'maybe fit'. However, in the second year, the proportion of cases certified sick had reduced significantly (41%) and a larger proportion (19%) was advised on workplace adjustments. In the third year post-introduction, there was a slight rise in the proportion of cases certified sick; therefore, although there was a fall of 2% per annum in certification rates, this was not significant. CONCLUSIONS: In the first year post-fit note introduction, modifications to work were recommended for people who would previously have been declared fit. Trends analyses showed a slight decrease in the certification rate, possibly indicating GPs will become more practised in advising on workplace adjustments.

Comparison of work-related ill-health data from different GB sources.

BACKGROUND: A number of data sources help inform policy decisions regarding the risk of work-related ill-health. AIMS: To compare self-reported and medically reported data from multiple sources and discuss their benefits and limitations in providing estimates of work-related ill-health incidence in Great Britain. METHODS: Sources included The Health & Occupation Reporting network (THOR & THOR-GP (THOR in General Practice)) and the survey of Self-reported Work-related Illness (SWI). Results from SWI and THOR from GPs, rheumatologists, psychiatrists, dermatologists and respiratory physicians (2006-2009) were compared. THOR-GP data also included patient referrals information. RESULTS: Overall incidence rates were highest when calculated from self-reported data, and lowest from clinical specialists. SWI rates were higher than GP rates for mental ill-health (SWI 790, GP 500 per 100 000 persons employed) and 'other' diagnoses (SWI 368, GP 41), whereas incidence rates for musculoskeletal (SWI 670, GP 684) and skin diagnoses (SWI 38, GP 152) were higher from GPs. Very few cases of musculoskeletal and mental ill-health were referred to clinical specialists (<1%). Skin (15%) and respiratory (26%) cases were referred more frequently. Case mix varied by data source. CONCLUSIONS: SWI is more inclusive than THOR-GP; however, reports are unsubstantiated by medical opinion. Clinical specialist reports are subject to biases such as severity and referral patterns. GP data benefit from their inclusion of less severe cases than reports from secondary care and may give a better reflection of the incidence of diseases with a work-related aetiology unrecognized by self-reporting individuals.

Work-related sickness absence as reported by UK general practitioners.

BACKGROUND: Issues surrounding sickness absence are of interest due to growing awareness of the costs to employers and the UK economy, a greater understanding of the interaction between health and work, and increasing evidence that work is beneficial to physical and mental well-being. The Health & Occupation Reporting network in General Practice (THOR-GP) is a national source of information on work-related sickness absence. AIMS: To assess the factors influencing work-related sickness absence in the UK. METHODS: General practitioners (GPs) report cases of work-related ill-health via an online web form. Sickness absence information reported with each case was compared by demographic information, diagnosis/symptom and employment factors. RESULTS: Between 2006 and 2009, THOR-GP received 5683 case reports of work-related ill-health; 53% were musculoskeletal diagnoses and 31% were mental ill-health diagnoses. Over half (56%) of cases reported had associated sickness absence. Diagnosis had a highly significant influence on the occurrence of any associated sickness absence. Eighty-one per cent of mental ill-health cases were reported to result in sickness absence compared to 50% of musculoskeletal cases. Public sector employees incurred sickness absence more frequently than those from the private sector. Industries with the highest mental ill-health incidence rates had sickness absence episodes most frequently. Within employment groups, levels of sickness absence were inversely proportional to the level of self-employment. CONCLUSIONS: These data reported by GPs with vocational training in occupational medicine may help to inform policy decisions targeting work-related exposures and the management of sickness absence, thereby reducing the UK burden of work-related sickness absence.

Occupation and work-related ill-health in UK construction workers.

BACKGROUND: Construction workers are at increased risk of work-related ill-health (WRI) worldwide. AIMS: To compare the incidence of medically reported WRI in occupations within the UK construction industry according to job title. METHODS: We calculated standardized incidence rate ratios (SRRs) using WRI cases for individual job titles returned to The Health and Occupation Reporting network by clinical specialists and UK population denominators. We counted frequencies of reported causal exposures or tasks reported by clinical specialists, occupational physicians and general practitioners. RESULTS: We found significantly increased incidence of WRI compared with other workers in the same major Standard Occupational Classification, i.e. workers with similar levels of qualifications, training, skills and experience, for skin neoplasia in roofers (SRR 6.3; 95% CI: 3.1-13.1), painters and decorators (2.1; 95% CI: 1.2-3.6) and labourers in building and woodworking trades (labourers, 6.6; 95% CI: 3.2-13.2); contact dermatitis in metal workers (1.4; 95% CI: 1.1-1.7) and labourers (1.6; 95% CI: 1.1-2.3); asthma in welders (3.8; 95% CI: 2.8-5.0); musculoskeletal disorders in welders (1.7; 95% CI: 1.1-2.8), road construction operatives (6.1; 95% CI: 3.8-9.6) and labourers (2.5; 95% CI: 1.7-3.7); long latency respiratory disease (mesothelioma, pneumoconiosis, lung cancer, non-malignant pleural disease) in pipe fitters (4.5; 95% CI: 3.2-6.2), electrical workers (2.7; 95% CI: 2.4-3.2), plumbing and heating engineers (2.3; 95% CI: 1.9-2.7), carpenters and joiners (2.7; 95% CI: 2.3-3.1), scaffolders (12; 95% CI: 8-18) and labourers (3.3; 95% CI: 2.6-4.1). CONCLUSIONS: UK construction industry workers have significantly increased risk of WRI. These data in individual construction occupations can be used to inform appropriate targeting of occupational health resources.

Surveillance for work-related audiological disease in the UK: 1998-2006.

BACKGROUND: Noise-induced hearing loss (NIHL) from prolonged occupational exposure to noise continues to rank among the top worldwide work-related ill-health problems. AIMS: To provide an overview of incident cases based on work-related audiological ill-health data collected over a 9-year period from occupational physicians (OPs), audiological physicians (APs), general practitioners and otorhinolaryngologists. METHODS: Analysis of numerator data reported by physicians to surveillance schemes within The Health and Occupation Reporting network (THOR). The actual cases were multiplied by the sampling ratio to provide estimated numerator numbers, followed by calculation of incidence rates using denominator data derived from the Labour Force Survey and from surveys of participating OPs. RESULTS: Two thousand five hundred and eighty-two estimated cases (2584 estimated diagnoses) were received from OPs (Occupational Physicians Reporting Activity [OPRA]), and 2192 estimated cases (3208 estimated diagnoses) of work-related audiological ill-health were received from consultant APs [Occupational Surveillance Scheme for Audiological physicians (OSSA)] from 1998 to 2006. Cases where the causal agent was noise exposure (NIHL and tinnitus) made up of 95 and 97% of all cases reported to OPRA and OSSA, respectively. The annual average incidence rate for noise-induced audiological disorders was 7.9 [95% confidence interval (CI) 4.6-11.1] per 100 000 persons employed (OPRA) and 0.8 (95% CI 0.7-1.0) per 100 000 persons employed (OSSA). Workers with the highest incidence were older males employed in public administration and defence and the manufacture of metals. CONCLUSIONS: THOR data show that diagnoses related to work-related noise exposure (NIHL/tinnitus), as reported to THOR, remain important health problems, despite preventive measures being in place.

Improving estimates of specialist-diagnosed, work-related respiratory and skin disease.

BACKGROUND: Work-related skin and respiratory disease still constitute an important part of the work-related ill-health (WRIH) burden of Great Britain (GB). It is therefore important to be able to accurately quantify the true incidence of these two groups of disease. AIMS: To improve the accuracy of the methodology to estimate clinical specialist incidence rates, with a focus on skin and respiratory disease. Specifically, we sought to estimate the number of additional cases not captured by voluntary surveillance through The Health and Occupation Reporting (THOR) network and provide a better estimation of the true incidence of work-related skin and respiratory disease in GB. METHODS: Cases not captured by THOR in 2005-2007 due to non-participation of eligible clinical specialists and due to <100% response rates by THOR participants were estimated, and the numerator adjusted accordingly. Adjusted incidence rates were calculated using Labour Force Survey data as the denominator. RESULTS: During 2005-2007, 62% of skin cases and 60% of GB respiratory cases were likely to have been captured by THOR. After adjustment, dermatologist-derived incidence rates for skin disease were raised from 9 to 14 per 100,000 employed, while those for respiratory disease were raised from 10 to 17 per 100,000 employed. CONCLUSIONS: We have provided a significant improvement in the surveillance-based methodology used to estimate the number of cases of WRIH captured by THOR and hence enabled more accurate estimations of GB incidence rates for clinical specialist-reported WRIH.

Medically reported work-related ill-health in the UK agricultural sector.

BACKGROUND: Self-reported work-related ill-health (WRI) statistics suggest that agricultural workers in the UK are at an increased risk of musculoskeletal disorders (MSD), skin and respiratory disease. However, there is little comprehensive medically reported information on WRI in the UK agricultural sector. METHODS: Cases of WRI within the UK from 2002 to 2008, as reported to The Health and Occupation Reporting (THOR) network by occupational physicians, clinical specialists and general practitioners, were analysed. Directly standardized incidence rate ratios (SRRs) for the agricultural sector versus all other sectors were calculated for dermatological, musculoskeletal, respiratory and psychological illness, using as the standard population the UK working population as estimated from the Labour Force Survey. RESULTS: During 2002-08, 471 cases within the agricultural sector were reported to THOR (2% of all cases). Based on reports by clinical specialists, male agricultural workers aged <65 years had significantly raised SRRs for MSD (2.3, 95% CI 1.6-3.3), allergic alveolitis (32, 95% CI 19-51), asthma (1.9, 95% CI 1.2-3.0) and skin neoplasia (7.9, 95% CI 5.8-10.9) and a significantly reduced SRR for asbestos-related respiratory disease (0.4, 95% CI 0.2-0.7). Reports of mental ill-health in agricultural workers were low. CONCLUSIONS: These medically reported incidence data provide information on WRI in the UK agricultural sector. Consistent with other sources, there are increased risks for asthma, allergic alveolitis and MSD and a reduced risk for mental ill-health. The raised incidence of skin cancer requires confirmation and further comparison with reliable estimates of the incidence in the UK workforce.

Comparison of work-related ill health reporting by occupational physicians and general practitioners.

BACKGROUND: The provision of occupational health (OH) services to the UK population is limited and concentrated in certain industries. Occupational physicians (OPs) therefore see a different subset of the population than general practitioners (GPs) and their recognition of work-related ill health may differ. AIMS: To examine how reports submitted by OPs and GPs compare and to discuss how biases may affect diagnostic and demographic differences. METHODS: The Health & Occupation Reporting network collects information on work-related ill health. OPs and GPs report case details, including demographic information, occupation, industry and suspected agent/task/event. Differences in reporting patterns were assessed. RESULTS: Musculoskeletal and mental ill-health reports made up over 80% of reports to both schemes although the likelihood ratio (LR) showed OPs were 78% more likely to report a psychological case than GPs. OPs were also more (18%) likely to report a female case. Health & social care was the industry most frequently reported by both groups; however, this was in greatly differing proportions (OPs 38%, GPs 14%). When LRs were adjusted for industry, this reduced the likelihood of an OP reporting cases of mental ill health (to 40%) and found them 10% less likely to report females than GPs. CONCLUSIONS: OP and GP reporting patterns highlight the variation in OH provision and its influence on the data provided. OPs are best placed to report on health and work relationships; however, as some sectors have poor access to OH services, reports from suitably trained GPs will help inform about this 'blind spot'.

The validity and reliability of diagnoses of work-related mental ill-health.

OBJECTIVES: To establish the reliability and validity of work-related mental ill-health diagnoses. BACKGROUND: A UK-based surveillance scheme for work-related ill-health involving occupational physicians (OPs) reporting suggests that mental ill-health incidence is increasing by around 13% per year, with anxiety, depression and "other work-related stress" being the most common diagnoses. There have been no studies of the validity and reliability of such diagnoses. Given the existence of a large network of psychiatrists (PSYs) also involved in surveillance of work-related ill-health, an opportunity arose to measure the concurrent validity and reliability of work-related mental ill-health diagnoses. METHODS: 100 anonymised summaries of cases previously reported by OPs or PSYs were collected; each was sent to 5 PSYs and 5 OPs, who assigned a diagnosis and judged whether the case was work-related. Concurrent validity of the ill-health aspect of the diagnoses, and of the opinion as to work-relatedness, was assessed by comparing the overall classifications of cases by OPs and PSYs. Reliability of the diagnostic classification was measured by kappa matrices. RESULTS: Diagnostic proportions for PSYs and OPs demonstrated good agreement for anxiety, depression, anxiety plus depression and "stress" (11%, 34%, 27%, 14%) and (14%, 30%, 27%, 17%), respectively. In both groups, kappa coefficients were high for a psychotic diagnosis (0.78, 95% CI: 0.74 to 0.83), but not as high for anxiety (0.27, 95% CI: 0.23 to 0.32), depression (0.34, 95% CI: 0.29 to 0.38) and "stress" (0.15, 95% CI: 0.10 to 0.19). The odds ratio of classifying a case as work-related among PSYs compared to OPs was 2.39 (95% CI: 1.68 to 3.38), p<0.001. CONCLUSIONS: The overall agreement between OPs and PSYs on mental ill-health diagnoses suggests that OP diagnoses are valid for epidemiological purposes. However, the within-group reliability of the diagnosis "stress" is low. Given differences in judgements about work-relatedness, further research is needed to investigate this aspect of a diagnosis.

The incidence of occupational skin disease as reported to The Health and Occupation Reporting (THOR) network between 2002 and 2005.

BACKGROUND: Estimated incidence rates for occupational skin disease in the U.K. are provided by voluntary surveillance schemes involving dermatologists and occupational physicians. These rates allow monitoring of occupational dermatoses, and intervention planning aimed at reducing workplace risks. OBJECTIVES: To summarize occupational skin disease reported to The Health and Occupation Reporting (THOR) network (2002-2005), and to provide baseline information for comparison with future studies of occupational skin disease in the U.K. and beyond. METHODS: Incidence rates for occupational dermatoses were calculated using THOR data as numerators, and Labour Force Survey data or information from the most recent U.K. survey on provision of occupational physician services as denominators. RESULTS: In the U.K. (2002-2005) the average annual incidence rate of work-related skin disease reported to THOR by dermatologists was 91.3 [95% confidence interval (CI) 81.8-101.1] per million, and by occupational physicians was 316.6 (95% CI 251.8-381.3) per million. Most reports were of contact dermatitis: dermatologists 68.0 (95% CI 59.8-76.2) per million, occupational physicians 259.7 (95% CI 200.8-318.6) per million. CONCLUSIONS: Information produced by THOR is an important source for calculating incidence rates of occupational skin disease. A range of reporting groups should also be used when building an overall picture of occupational skin disease incidence in the U.K.

Work-related infectious disease reported to the Occupational Disease Intelligence Network and The Health and Occupation Reporting network in the UK (2000-2003).

BACKGROUND: Infectious diseases remain an important cause of self-reported work-related illness, with socio-economic consequences, including sickness absence. Reporting of infectious disease by occupational and specialist physicians is an important tool in the investigation of occupationally related infections and is relevant in their management. AIMS: To examine the reporting of cases of infectious disease by occupational and specialist physicians to schemes collecting data on occupational ill-health. METHODS: Cases of infectious disease reported by occupational and specialist physicians to the UK based schemes, Occupational Disease Intelligence Network (ODIN) and The Health and Occupation Reporting network (THOR), from 2000 to 2003 were analysed by reporting patterns, diagnosis, single case or outbreak reporting and industry. RESULTS: The total number of estimated cases of infectious disease reported to ODIN and THOR from 2000 to 2003 was 5606; 74.9% cases were diarrhoeal disease, and 11.1% scabies. The majority (81.4%) of cases were reported in SIDAW, where the participation rate for reporters was 55%. Reporting rates were much higher in OPRA, SWORD and EPIDERM (ranging from 86 to 96%). The most frequently reported industrial sectors were social care (39.5%) and health (29.4%); while the manufacture of chemical products contributed 4.3% overall, but 33.8% to estimated cases in OPRA. CONCLUSIONS: Despite limitations related to under reporting, the occupational and specialist physician schemes in ODIN and THOR provide data that may be used to look at patterns of case reporting for occupational ill-health, including infectious disease. The reporting schemes also provide an important means of alerting peers about potential novel causes, precipitating factors, or industrial sectors associated with occupational disease.

Physicians' beliefs in the assessment of work attribution when reporting musculoskeletal disorders.

BACKGROUND: There is considerable uncertainty about work-relatedness and musculoskeletal disorders in general, and it is also not clear how physicians decide whether work has caused a disorder in an individual patient. AIMS: To investigate physicians' beliefs about assessment of occupational attribution for work-related musculoskeletal disorders. METHODS: A questionnaire survey was sent to 526 occupational physicians and 248 rheumatologists on: characteristics of cases seen, assessment of work attribution, definition of work-relatedness and threshold for case reporting. Continuous variables were analysed by mean, standard deviation, an independent two-sample t-test and the Mann-Whitney test. Mean and median values were calculated and Spearman's rank test was applied to ranked data. RESULTS: Questionnaires were completed by 68% occupational physicians and 64% rheumatologists. Both groups of physicians believed that 'history of onset in relation to workplace changes' and 'symptoms consistent with work exposure' were the most important factors suggesting work attribution. They considered that the most important objective of a reporting scheme was detection of trends in disease incidence and that the most suitable criteria for defining work-relatedness was the probability that exposure at work 'more likely than not' caused the condition (mean 0.73; SD=0.17), in a perceived likelihood scale (0-1). CONCLUSION: There was a strong agreement between occupational physicians and rheumatologists on questions about work-relatedness and musculoskeletal disorders. The level of probability for concluding work-relatedness has been quantified.