A facilitated early return to work program at a large urban medical center.

An Early Return to Work Program was initiated at The Johns Hopkins Hospital and Associated Schools of Medicine, Hygiene and Nursing in Baltimore, Maryland, in April 1992 as part of a comprehensive effort to control the incidence and costs of work-related illnesses and injuries. The program was similar to others that incorporate employee and supervisory training and job accommodation, but it also included an industrial hygienist trained in ergonomics to facilitate the placement of individuals with restrictions. The return to work program was studied over a 10-year period, comparing the number of lost workday cases, lost workdays, and restricted duty days before (1989 to 1992) and after (1993 to 1999) initiation of the program. A significant decrease (55%) was observed in the rate of lost workday cases before versus after the return to work program. Furthermore, the number of lost workdays decreased from an average of 26.3 per 100 employees before, to 12.0 per 100 employees after, the return to work initiative, and the number of restricted duty days went from an average of 0.63 per 100 employees to 13.4 per 100 employees (a twentyfold increase). The study suggests that a well-structured early return to work program is an integral part of a comprehensive effort to control the duration of disability associated with occupational injuries and illness. It also indicates that to be most effective, an early return to work program must include participation by medical providers, safety professionals, injured employees, and supervisors. Our work suggests that even with these elements in place, the effectiveness of return to work programs may be increased by including an individual trained in ergonomics to facilitate the job placement process.

An ergonomics program designed to reduce the incidence of upper extremity work related musculoskeletal disorders.

In 1992, the Johns Hopkins Hospital and University initiated a program aimed at the early diagnosis and treatment of potential upper extremity work related musculoskeletal disorders (UEWMSDs), ergonomic assessment and abatement of work areas where individuals with UEWMSDs are employed, as well as the identification and correction of areas throughout the hospital and university where UEWMSDs could possibly occur. The program resulted in an initial increase in the number and cost for the treatment of UEWMSDs. Subsequently, there was a significant decrease in the number of UEWMSDs reported and virtual elimination of the need to use surgical procedures to correct these conditions. This article suggests that a coordinated program of medical care, ergonomic assessment, and intervention can be efficacious in the primary, secondary, and tertiary prevention of UEWMSD.

The effect of managed care on surgical rates among individuals filing for workers' compensation.

This work evaluates the imposition of managed care techniques on the rate of claims and surgeries utilizing a pre- versus post-program analysis. The purpose was to ascertain whether managed care techniques--specifically, an ergonomic program, medical treatment guide-line, nurse case management, and utilization of a preferred provider organization consisting of academic physicians--would reduce the rate of the claims and surgery in a population of predominantly health care and university workers. The claims frequency rate and surgical frequency rates per 1,000 employees and per 1,000 claims was significantly lower during the managed care period than during the year prior to the initiation of managed care. The distribution of surgical procedures, as well as the duration of disability in the years of injury, after the initiation of managed care (1993-1997) were different from those same parameters in the fiscal years prior to the initiation of managed care (1990-1992). The results suggest that even in the workers' compensation environment, where financial incentives encourage a higher claims and surgical frequency rate than do the fee-for-service or prepaid medical environments, managed care techniques can be successfully utilized. A unique feature of the study was the use of university-based physicians as a specific managed care technique to influence surgical rates.

Managed care for workers' compensation: three years of experience in an "employee choice" state.

Managed care techniques are becoming increasingly available to manage the medical indemnity losses associated with injuries paid for under the workers' compensation system. The authors describe 3 years' experience of identifying and abating workplace hazards and medically managing cases utilizing a preferred provider organization established solely for workers' compensation cases. In the model described, the occupational physician/nurse case-management team coordinates the entire process, from prevention of accidents to facilitated return to work. During the study period (1992 to 1995), per-capita losses were reduced by 23%, from $241 in fiscal year 1992 (the year before the managed care initiative), to $185 in fiscal year 1995. (Hereafter, each year referred to indicates that fiscal year.) In 1992, 22 lost-time cases per 1000 employees occurred, whereas the number of lost-time cases in the years 1993 to 1995 averaged 12 to 14 per 1000 employees. The rate of "medical only" cases dropped significantly from 155 per 1000 in 1992 to 96 per 1000 in 1995. The per-capita amount of monies spent on medical care decreased from $81 in 1992 to $63 in 1995. The most significant savings in medical costs related to claims associated with new occupational injuries, injuries that occurred during the fiscal year. In 1992, the per-capita loss on such cases was $23 and in 1995 it was $13, a 43% decrease. The number of temporary/total days dropped significantly from 163 per 100 employees in 1992 to 70 days in 1995. Concurrently, the per-capita loss for temporary total disability was reduced from $53 in 1992 to $26 in 1995. Per-capita administrative costs, as well as other indemnity losses (predominantly permanent partial disability), decreased only slightly over the study period ($58 to $54 and $60 to $51, respectively). We feel that these results indicate that environmental-risk management and medical-care management can be integrated to produce substantial savings. It also suggest that managed-care techniques, which are becoming more available to employers, can even be applied in status that do not have managed care legislation.

A comprehensive initiative to manage the incidence and cost of occupational injury and illness. Report of an outcomes analysis.

A comprehensive initiative utilizing an in-house preferred provider organization, medical case management, and application of ergonomic techniques was implemented in an effort to control the incidence and cost of workplace injuries. The program was evaluated utilizing OSHA 200 Logs to compare the incidence and lost time due to compensable injury and illnesses before and after beginning the program. After the introduction, there was a significant decrease in injuries and illnesses (53/1000 vs 27/1000, P<.01) and average days lost per event (10.4 vs 6.6 days, P<.01). A significant increase in restricted-duty days (.2 vs 1.5 days, P<.01) and an 18% reduction in medical and indemnity costs of the institution's workers' compensation expenditures were observed. This study demonstrates the initial effectiveness of an aggressive ergonomic and managed care approach to reducing the incidence, severity, and cost of occupationally related injury and illness. It also highlights the effectiveness of an outcomes analysis approach, using lost time as an end point, to measure the effectiveness of preventive and management strategies in the workers' compensation setting.

Prevalence of hepatitis B, hepatitis C, and human immunodeficiency virus markers among hospital employment applicants.

To delineate baseline seroprevalence rates before job placement, applicants for employment (n = 300) at a large urban medical center were screened for serologic markers to the hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) during a 15-week period in 1992. Eighteen applicants (6%) were positive for antibodies to HBV, nine (3%) for HCV, and 3 (1%) for HIV. There was no association by gender for any of these viral markers; however, both HBV and HCV were significantly more often detected in persons applying for hourly positions who were black. In an urban setting, preemployment screening of health care workers for HBV and HCV markers appears warranted, and serum banking for later HIV analysis, should a claim arise, is suggested.

Preemployment drug screening at the Johns Hopkins Hospital, 1989 and 1991.

During identical 2-month periods in 1989 and 1991, all applicants for employment at a major teaching hospital participated in preemployment drug screening. In 1989, before establishment of a formal preemployment testing program, screening was conducted without identifying information. Of 593 applicants screened, 64 (10.8%) were confirmed positive for one or more drugs. Marijuana metabolites were detected with the greatest frequency (35 samples, 55% of positive screens), followed by cocaine (36%), then opiates (28%). In 1991, after a formal preemployment testing program was in place, 365 applicants were screened, and 21 (5.8%) were confirmed positive. Opiates were most often detected (48% of positive screens), followed by cocaine (38%), then marijuana metabolites (28%). During both periods, positive urine screens were associated with ethnicity (non-White) and occupational category (blue-collar). Whereas in 1989 positive screens were associated with male gender, in 1991, females were more likely to test positive. The decline in prevalence following implementation of a screening program supports the notion that preemployment testing can serve as a deterrent for drug-using persons in applying for employment.

A profile of health risks among blue-collar workers.

Despite national objectives for extending health promotion programs to blue-collar workers and to small work sites, baseline behavior information for planning such programs is lacking. This study seeks to describe the health risks and norms specific to a population of male, blue-collar gas pipeline workers in remote sites. These workers (n = 395) completed a health risk appraisal and a "health gauge" survey designed to measure nutrition, physical activity, tobacco use, participatory patterns in health-enhancing activities, group norms, and change efforts. Selected behaviors were similar to those of other Texas men (eg, smoking 27% versus 26%) although others were not (eg, smokeless tobacco 18% versus 8%). Multivariate analysis confirmed the relationship of friends' behavior patterns, risk-taking, and interpersonal experience to four lifestyle health behaviors. With 75% or more of workers expressing an interest in various programs, the findings suggest that programming for this population can be successful if tailored to current behaviors and the worksite culture.

The relationship between work-related and non-work-related injuries.

A case-control study of occupational injuries sustained by 914 male hourly workers employed in two Tenneco manufacturing divisions in 1987 was undertaken to examine the association between occupational and non-occupational injuries. Its aim was to evaluate whether employees who experienced a work-related injury were more likely to have sustained a previous non-work-related injury compared to individuals who did not experience a work-related injury. A statistically significant association between occupational injuries and past non-occupational injuries was seen when all workers compensation (WC) claims were analyzed (OR = 1.41) and when claims involving indemnity for lost time were analyzed (OR = 1.82). In addition, both workers who had occupational low-back injuries and workers who had occupational non-low-back injuries also had significantly higher risks of such injuries from a non-occupational origin (OR = 1.91 for low-back injuries and OR = 1.44 for non-low-back injuries). The findings suggest that elements other than workplace hazards (such as life-style and physical and psychological factors) may predispose an individual to both occupational and non-occupational injuries.

Health care utilization and costs for injury in a corporate setting.

This article presents the incidence and costs for non-work-related injuries among 15,408 employees and their families based on health insurance claims data analysis. The treatment of injuries accounted for 11.3% of the plan's total health care costs ($31 million) for the 1986 policy year. For adults, women had a higher incidence rate than men; but for children, males had a higher incidence rate than females. A disproportionately high share of claims and charges for adults were attributed to low back disorders. Hospital admissions, length of stay and hospital days per 1,000 persons were similar for males and females, but much higher for adults than for children. This article provides an example of the utility of health insurance claims data as a source of morbidity information for disease surveillance and epidemiologic research. The analysis of claims data can be seen as a prerequisite to the development of preventive programs aimed at reducing injury rates and health care costs for injuries in a corporate setting.

Incidence and cost of injury in an industrial population.

Using both occupational (workers' compensation) and non-occupational (group health insurance) data, the nature and magnitude of injuries were determined in a working population of 20,705. Approximately one third of the population sustained an injury in 1986 (the year of study). Men experienced a significantly higher injury rate than women (33.3 per 100 v 24.9 per 100) and hourly employees had significantly higher incidence rates than salaried employees (42.0 per 100 v 22.5 per 100). The majority of nonoccupational injury claims were for low back disorders, whereas most occupational injury claims were related to superficial wounds and contusions. Overall, the incidence of nonoccupational injuries (21.1 per 100) was twofold higher than that of occupational injuries (10.8 per 100). Total costs for occupational and nonoccupational injuries were $4.97 million. The per-capita costs were $120 for both nonoccupational and occupational injuries. However, if only health care expenses are included in this calculation, nonoccupational injury costs would be almost 3 times as high as occupational injury costs ($120 v $46). These findings argue for increasing the share of corporate resources for off-the-job injury prevention programs aimed at reducing injury incidence and resultant health care costs.

Participation in a periodic physical examination program and group health care utilization and costs.

The authors identified 710 male employees of a multinational US corporation eligible to take periodic physical examinations for a consecutive 3-year period (1983 to 1985) and insured by one of the company's health insurers. Group health insurance claims rates and costs for the calendar year 1985 were studied among executives who did not take an examination during the study period, those who took it once or twice, and those who took it all 3 years. Health care utilization for those who did not participate in the program was significantly lower than both groups of participants. Average claim costs in 1985 among those who participated all 3 years ($1,039) was 1.77 times the cost of those who participated one or two times ($588) and 2.30 times the cost of those who did not participate ($452). We conclude that short-term health care utilization and costs are higher among participants than non-participants of a periodic physical examination program.

Injury prevalence and associated costs among participants of an employee fitness program.

The prevalence, cost, and type of injury among participants of an employee fitness program and nonexercising co-workers were studied over a 2-year period from 1984 to 1985. The purpose of the study was to determine whether participants of an employee fitness program (n = 2,871) experienced a greater risk of injury and resultant higher costs than nonparticipants (n = 3,233). Overall, there were no significant differences in the rate or cost of injuries among the various participation levels (from 0 to 3 or more times per week). However, the data indicated that individuals who occasionally participated in the fitness program experienced a greater, but nonsignificant, risk of injury (6.3 per 100 persons who exercised less than 1 session per week, and 7.7 per 100 persons who exercised 1-2 sessions per week) than nonparticipants (5.7 per 100 persons). Injury prevalence was lower among individuals who exercised 3 or more sessions per week (5.4 per 100 persons) as was the resultant per capita cost of injuries ($32 vs $42 for nonparticipants). We conclude the impact of exercise at an onsite health and fitness facility on overall injury rates and costs among employees is negligible.

Obesity and morbidity prevalence in a working population.

As part of ongoing medical surveillance, the morbidity prevalence for obese individuals (20% to 40% and greater than 40% overweight) was compared with non-obese corporate employees utilizing group health insurance claims data for 1985. The advantages of claims data as a potential source of morbidity data for disease surveillance and research are discussed herein. The expected finding of a positive association between hypertension (P less than .05) and obesity noted for both male and female employees reiterates the important role of work site weight control programs in reducing hypertension. The positive association between prevalence of mental health disorders and obesity demonstrates the need to address the adverse psychologic risks of obesity in addition to the adverse physical risks. This finding suggests that employee assistance programs emphasize counseling services for obese individuals.

Effect of curtailed insurance benefits on use of mental health care. The Tenneco health plan.

This article presents the impact of a health insurance benefit redesign on utilization and costs for mental health care in a large corporation. The design change primarily limited coverage to 45 days of hospitalization and 20 outpatient visits. Group health insurance data before and after the benefit changes (effective January 1, 1984) were compared and analyzed. Per capita charges for mental health care between 1983 and 1985 decreased by 41%, from $89 to $53. Responses to the benefit modifications differed for inpatient and outpatient services. Inpatient costs and length of stay decreased dramatically, especially for dependents, while utilization rates remained about the same. Statistically significant increases occurred for outpatient care utilization and costs.

Health care utilization and costs for diseases of the circulatory system in a corporate setting.

This article presents the health care utilization and costs for diseases of the circulatory system among 14,162 employees and their spouses based on medical insurance claims data analysis. Diseases of the circulatory system ranked first among insurance claims and costs accounting for 23% ($4.6 million) of the plan's total health care costs ($19.7 million) for the 1984 policy year. Overall, 57% of these expenditures were for hospital care, the proportion for hospital costs being as high as 64% for heart diseases and as low as 20% for hypertension. Male employees had higher utilization for both in-hospital and out-patient services than females. Utilization rates and costs dramatically increased for individuals 50 years or older. Costs for surgical and diagnostic procedures amounted to 8% of the total costs of circulatory system disorders. This article provides an example of the utility of claims analysis for morbidity surveillance. The analyses and parameters measured herein can be viewed as prerequisites to the development of health care management and health promotion strategies aimed at reducing health care cost for diseases of the circulatory system in a corporate setting.

Mental health care utilization and costs in a corporate setting.

This article presents the mental health care utilization and costs among 14,162 employees and their families, covered under a major medical policy of a large multinational corporation for the 1984 policy year. Mental health care costs comprise a substantial portion of the total health care dollars expended (8.1%) for a relatively small fraction of the total number of claims (2.8%). The average hospital stay for mental disorders (20 days for employees; 15 days for spouses; 43 days for dependents) was significantly longer than for other illnesses (6.1 days for employees; 6.2 days for spouses; 4.4 days for dependents). Although the average daily hospital cost for mental disorders was less than that for non-mental conditions, total expenditures per admission were approximately three times higher due to the long lengths of stay. Case management, peer utilization review, and day treatment are recommended to reduce these costs.

Relationship of employee turnover to exercise adherence in a corporate fitness program.

The life table method of analysis was used to study the differences in turnover during a 4-year period among employees who participated in a corporate health and fitness program and those who did not. The study population consisted of 1,360 workers hired between Jan 1, 1982, and Dec 31, 1985, of whom 747 were exercisers; and 1,788 persons hired between Jan 1, 1978, and Dec 31, 1981, of whom 869 were exercisers. Age, sex, general job category, and duration of employment were taken into account in the analysis. For both groups the probability of continued employment among exercisers was significantly greater than among nonexercisers. The differences were particularly profound among female clerical employees. The study did not attempt to assess the causal nature of this relationship. However, we speculate that health and fitness programs influence turnover in employment groups where the personal financial benefits are the greatest.