Physician Engagement in Malpractice Risk Reduction: A UPHS Case Study.

BACKGROUND: The University of Pennsylvania Health System (UPHS) implemented a risk reduction strategy in response to high malpractice costs and the broader implications these trends had for patient safety and quality. A key component of this strategy was the Risk Reduction Initiative (RRI), which uses a bottom-up approach to actively engage physicians in risk mitigation and malpractice reduction within their respective departments. METHODS: The value of clinical communities in achieving common goals has been previously recognized in quality improvement efforts. Using a physician-directed approach, the RRI program requires each clinical department to propose and execute an intervention in response to prior malpractice claims data or recognition of an area of high risk. Based on the success of the intervention, clinical departments were eligible to receive a financial rebate for use in future quality improvement projects. RESULTS: Clinical departments have led the development and implementation of interventions that have shown demonstrable improvements in quality and safety and thereby received full financial rebates. On a system level, the inclusion of physicians in risk mitigation efforts has resulted in significant benefits from both quality improvement and financial standpoints. The number of malpractice claims and malpractice cost have decreased since the inception of the program. CONCLUSION: Since the program inception, 250 proposals have been submitted and $14 million in rebates have been awarded. Although it is difficult to directly measure the combined impact of these bottom-up, physician-directed interventions, empowering frontline physicians to become actively involved in risk mitigation is a promising method for reducing malpractice claims and costs.

The health of young US workers.

OBJECTIVES: To provide an overview of the health status of young US workers across four domains: functional health, physical and psychological health, health behavior, and health care utilization. METHODS: Pooled data from the 2004 to 2010 National Health Interview Survey were analyzed for 11,279 US workers aged 18 to 24 years, representing an estimated 16.9 million workers annually. Thirty-nine health indicators were examined and compared across nine occupational groups. RESULTS: Compared with other occupational groups, craft workers and laborers and helpers had the highest prevalence of risky health behaviors, including current smoking and risky drinking, as well as fewer reported visits to a primary care physician in the past year. CONCLUSIONS: Young workers engage in risky health behaviors, and may benefit from targeted workplace interventions to mitigate the potentially negative long-term effects on health and well-being.

A new approach to the characterization of subtle errors in everyday action: implications for mild cognitive impairment.

Mild functional difficulties have been associated with early cognitive decline in older adults and increased risk for conversion to dementia in mild cognitive impairment, but our understanding of this decline has been limited by a dearth of objective methods. This study evaluated the reliability and validity of a new system to code subtle errors on an established performance-based measure of everyday action and described preliminary findings within the context of a theoretical model of action disruption. Here 45 older adults completed the Naturalistic Action Test (NAT) and neuropsychological measures. NAT performance was coded for overt errors, and subtle action difficulties were scored using a novel coding system. An inter-rater reliability coefficient was calculated. Validity of the coding system was assessed using a repeated-measures ANOVA with NAT task (simple versus complex) and error type (overt versus subtle) as within-group factors. Correlation/regression analyses were conducted among overt NAT errors, subtle NAT errors, and neuropsychological variables. The coding of subtle action errors was reliable and valid, and episodic memory breakdown predicted subtle action disruption. Results suggest that the NAT can be useful in objectively assessing subtle functional decline. Treatments targeting episodic memory may be most effective in addressing early functional impairment in older age.

Examining national trends in worker health with the National Health Interview Survey.

OBJECTIVE: To describe data from the National Health Interview Survey (NHIS), both the annual core survey and periodic occupational health supplements (OHSs), available for examining national trends in worker health. METHODS: The NHIS is an annual in-person household survey with a cross-sectional multistage clustered sample design to produce nationally representative health data. The 2010 NHIS included an OHS. RESULTS: Prevalence rates of various health conditions and health behaviors among workers based on multiple years of NHIS core data are available. In addition, the 2010 NHIS-OHS data provide prevalence rates of selected health conditions, work organization factors, and occupational exposures among US workers by industry and occupation. CONCLUSIONS: The publicly available NHIS data can be used to identify areas of concern for various industries and for benchmarking data from specific worker groups against national averages.

Prevalence and work-relatedness of carpal tunnel syndrome in the working population, United States, 2010 National Health Interview Survey.

BACKGROUND: Patterns of prevalence and work-relatedness of carpal tunnel syndrome (CTS) among workers offer clues about risk factors and targets for prevention. METHODS: Data from an occupational health supplement to the 2010 National Health Interview Survey were used to estimate the prevalence of self-reported clinician-diagnosed CTS overall and by demographic characteristics. The proportion of these cases self-reported to have been attributed to work by clinicians was also examined overall and by demographic characteristics. In addition, the distribution of industry and occupation (I&O) categories to which work-related cases of CTS were attributed was compared to the distribution of I&O categories of employment among current/recent workers. RESULTS: Data were available for 27,157 adults, including 17,524 current/recent workers. The overall lifetime prevalence of clinician-diagnosed CTS among current/recent workers was 6.7%. The 12-month prevalence was 3.1%, representing approximately 4.8 million workers with current CTS; 67.1% of these cases were attributed to work by clinicians, with overrepresentation of certain I&O categories. CONCLUSIONS: CTS affected almost 5 million U.S. workers in 2010, with prevalence varying by demographic characteristics and I&O.

Prevalence of dermatitis in the working population, United States, 2010 National Health Interview Survey.

BACKGROUND: Prevalence patterns of dermatitis among workers offer clues about risk factors and targets for prevention, but population-based estimates of the burden of dermatitis among US workers are lacking. METHODS: Data from an occupational health supplement to the 2010 National Health Interview Survey (NHIS-OHS) were used to estimate the prevalence of dermatitis overall and by demographic characteristics and industry and occupation (I&O) of current/recent employment. RESULTS: Data were available for 27,157 adults, including 17,524 current/recent workers. The overall prevalence rate of dermatitis among current/recent workers was 9.8% (range among I&O groups: 5.5-15.4%), representing approximately 15.2 million workers with dermatitis. The highest prevalence rates were among I&O groups related to health care. Overall, 5.6% of dermatitis cases among workers (9.2% among healthcare workers) were attributed to work by health professionals. CONCLUSIONS: Dermatitis affected over 15 million US workers in 2010, and its prevalence varied by demographic characteristics and industry and occupation of employment. The prevalence rate of work-related dermatitis based on the NHIS-OHS was approximately 100-fold higher than incidence rates based on the Bureau of Labor Statistics' Survey of Occupational Illness and Injury.

Risk factors, health behaviors, and injury among adults employed in the transportation, warehousing, and utilities super sector.

BACKGROUND: The TWU super sector is engaged in the movement of passengers and cargo, warehousing of goods, and the delivery of services. The purpose of this study is to describe employee self-reported personal risk factors, health behaviors and habits, disease and chronic conditions, and employer-reported nonfatal injury experiences of workers in the TWU super sector. METHODS: National Health Interview Survey (NHIS) data for 1997-2007, grouped into six morbidity and disability categories and three age groups, were reviewed. Demographic characteristics and prevalence estimates are reported for workers in the TWU super sector and the entire U.S. workforce, and compared with national adult population data from the NHIS. Bureau of Labor Statistics employer-reported TWU injury data from 2003 to 2007 was also reviewed. RESULTS: An average of 8.3 million workers were employed annually in the TWU super sector. TWU workers 65 or older reported the highest prevalence of hypertension (49%) across all industry sectors, but the 20% prevalence is notable among middle age workers (25-64). TWU workers had the highest prevalence of obesity (28%), compared to workers in all other industry sectors. Female TWU workers experienced the highest number of lost workdays (6.5) in the past year across all TWU demographic groups. CONCLUSIONS: Self-reported high proportions of chronic conditions including hypertension and heart disease combined with elevated levels of being overweight and obese, and lack of physical activity-particularly among TWUs oldest workers-can meaningfully inform wellness strategies and interventions focused on this demographic group. Am. J. Ind. Med. 56:556-568, 2013. © 2012 Wiley Periodicals, Inc.

Mortality among members of a truck driver trade association.

Previous studies report that truck drivers are at increased risk for illness and on-the-job mortality. It is unknown whether owner-operator truck drivers face the same risks as employee drivers, yet few studies have targeted owner-operators as a study population. This study examined the overall and cause-specific mortality ratios for a cohort with owner-operator truck drivers constituting 69% of the study population. Of the 26 major disease classifications and 92 specific causes of death examined, only mortality due to transportation accidents was significantly elevated (standardized mortality ratio=1.52, 95% confidence interval=1.36-1.70). Leading causes of death were ischemic heart disease and lung cancer, although risk was below that of the general population. Transportation accidents pose a particular hazard for members of the trade association. The absence of excess disease mortality deserves careful interpretation, and may be due to both a strong healthy worker effect and a short monitoring period.

Occupational fatalities, injuries, illnesses, and related economic loss in the wholesale and retail trade sector.

BACKGROUND: The wholesale and retail trade (WRT) sector employs over 21 million workers, or nearly 19% of the annual average employment in private industry. The perception is that workers in this sector are generally at low risk of occupational injury and death. These workers, however, are engaged in a wide range of demanding job activities and are exposed to a variety of hazards. Prior to this report, a comprehensive appraisal of the occupational fatal and nonfatal burdens affecting the retail and wholesale sectors was lacking. The focus of this review is to assess the overall occupational safety and health burden in WRT and to identify various subsectors that have high rates of burden from occupational causes. Ultimately, these findings should be useful for targeted intervention efforts. METHODS: We reviewed Bureau of Labor Statistics (BLS), 2006 fatality, injury, and illness data for the WRT sector and provide comparisons between the WRT sector, its' subsectors, and private industry, which serves as a baseline. The BLS data provide both counts and standardized incidence rates for various exposures, events, and injury types for fatalities, injuries, and illnesses. In an effort to estimate the economic burden of these fatalities, injuries, and illnesses, a focused review of the literature was conducted. RESULTS AND CONCLUSION: In 2006, WRT workers experienced 820,500 injuries/illnesses and 581 fatalities. The total case injury/illness rate for the retail sector was 4.9/100 FTE and for the wholesale sector 4.1/100 FTE. The WRT sector represents 15.5% of the private sector work population in 2006, yet accounts for 20.1% of nonfatal injuries and illnesses of the private sector. In 2003, the disparity was only 2% but increased to 3% in 2004 and 2005. Three WRT subsectors had injury/illness rates well above the national average: beer/wine/liquor (8.4/100); building materials/supplies (7.6/100); and grocery-related products (7.0/100). Occupational deaths with the highest rates were found in gasoline stations (9.8/100,000), convenience stores (6.1/100,000), and used car dealers (5.5/100,000). In terms of actual numbers, the category of food and beverage stores had 82 fatalities in 2006. Based on 1993 data, costs, both direct and indirect, in the WRT sector for fatal injuries were estimated to exceed $8.6 billion. The full economic loss to society and the family has not been adequately measured. Overexertion and contact with objects/equipment represent the top two events or exposures leading to injury or illness. Together they account for 57% of the events or exposures for nonfatal WRT injuries and illnesses. This sector is important because it is large and pervasive as a result, even a relatively small increase in injury rates and accompanying days away from work will have significant impact on working families and society.

Fatalities in the landscape and horticultural services industry, 1992-2001.

BACKGROUND: Although landscape and horticultural services workers have high injury and illness rates, little is known about fatalities in this industry. METHODS: Census of Fatal Occupational Injuries and Current Population Survey data were analyzed to determine fatality rates and causes of landscaping deaths from 1992 to 2001. RESULTS: There were 1,101 fatalities during the 10-year period and the average fatality rate was 13.50 deaths per 100,000 full-time employees. In 2001, the landscaping fatality rate was 3.33 (95% CI 2.84-3.91) times the all industry rate. The leading causes of death were transportation incidents (27%), contact with objects or equipment (27%), falls (24%), exposure to harmful substances and environments (18%), and assaults and violent acts (4%). The fatality rate for African American landscapers was 1.51 (95% CI 1.25-1.83) times the rate for white workers. Fatalities were also common among self-employed, small business, and young landscapers. CONCLUSIONS: Landscaping workers are at increased risk of fatal injury. Further research is needed to characterize industry hazards.

Characteristics of US workers whose blood lead levels trigger the medical removal protection provision, and conformity with biological monitoring requirements, 2003-2005.

BACKGROUND: Workers with blood lead levels (BLL) > or =60 microg/dl (50 microg/dl for construction workers) or with three or more consecutive BLLs over at least 6 months that average 50 microg/dl or greater are required to be removed from work involving lead exposure that exceeds the OSHA action level. This study estimates the proportion of workers with BLLs that trigger the medical removal provision by industry sector, and examines whether workers received appropriate follow-up blood lead testing. METHODS: Three years (2003-2005) of data from the Adult Blood Lead Epidemiology and Surveillance program were analyzed to identify those industries with a high percentage of workers with BLLs that trigger the medical removal provision. Adjusted rate ratios (RR) of adults with such BLLs were estimated by industry sector compared to the battery manufacturing industry using Poisson regression models. RESULTS: Out of 13,724 adults with BLLs > or =25 microg/dl, a total of 533 adults had BLLs that triggered the medical removal provision. RRs of adults with BLLs triggering medical removal were highest for "painting and wall covering contractors" (RR = 22.1) followed by "highway, street and bridge construction" (RR = 14.7), "amusement, gambling, and recreation" (RR = 11.4), and "glass product manufacturing" (RR = 10.1). Overall, 29% of adults with BLLs triggering medical removal received appropriate follow-up blood lead tests and met the eligibility to return to lead work. CONCLUSIONS: These findings suggest that additional efforts are needed to prevent occupational overexposure to lead in adults, and to ensure proper medical management of those workers who meet medical removal criteria.

Proportionate mortality of crop and livestock farmers in the United States, 1984-1993.

BACKGROUND: Livestock farmers are more likely to be exposed to a variety of different farming hazards than crop farmers. An analysis of occupation and industry-coded U.S. death certificate data from 26 states for the years 1984-1993 was conducted to evaluate mortality patterns among crop and livestock farmers. METHODS: Cause-specific proportionate mortality ratios (PMRs) were calculated using a National Institute for Occupational Safety and Health (NIOSH) computer program designed to calculate sex and race specific PMRs for occupations and industries in population-based data. RESULTS: Among white male (WM) livestock farmers, there was a significantly higher mortality from cancer of the pancreas, prostate and brain, non-Hodgkin's lymphoma (NHL), multiple myeloma, acute and chronic lymphoid leukemia, and Parkinson's disease. WM crop farmers showed significantly higher mortality risk for cancer of the lip, skin, multiple myeloma, and chronic lymphoid leukemia. CONCLUSIONS: These disease trends suggested that livestock farmers might be exposed to more carcinogens or agricultural chemicals than crop farmers.