Costs of hepatitis C.

OBJECTIVE: To estimate the direct and indirect costs of the hepatitis C virus (HCV) in the United States in 1997. DESIGN: Aggregation and analysis of national data sets collected by the National Center for Health Statistics, the Health Care Financing Administration, and other government bureaus and private firms. To estimate costs, we used the human capital method, which decomposes costs into direct categories, such as medical expenses, and indirect categories, such as lost earnings and lost home production. We consider HCV that results in chronic liver disease separate from HCV that results in primary liver cancer. RESULTS: We estimate $5.46 billion as the cost of HCV in 1997. Costs are split as follows: 33% for direct and 67% for indirect costs. Hepatitis C virus that results in chronic liver disease contributes roughly 92% of the costs, and HCV that results in primary liver cancer contributes the remaining 8%. The total estimate of $5.46 billion is conservative, because we ignore costs associated with pain and suffering and the value of care rendered by family members. CONCLUSIONS: To our knowledge, only one estimate of the annual costs of HCV in the 1990s has appeared in the literature, $0.6 billion. However, that estimate was not supported by an explanation of the methods. Our estimate, which relies on detailed methods, is nearly 10 times the original estimate. Our estimate of $5.46 billion is on a par with the cost of asthma ($5.8 billion [1994]).

Estimating the costs of job related arthritis.

OBJECTIVE: To present the first estimate of the costs of job related osteoarthritis (OA) in the USA. METHODS: Data were drawn from national data sets collected by the US Bureau of Labor Statistics, the US National Center for Health Statistics, and existing cost estimates for arthritis in the literature. We used proportional attributable risk (PAR) models to estimate the percentage of acute and repetitive injuries resulting in OA. These PAR vary between men and women. We used the human capital method that decomposes costs into direct categories such as medical expense and indirect categories such as lost earnings. RESULTS: We estimate job related OA costs US$3.41 to 13.23 billion per year (1994 dollars). Our point estimate is that job related OA contributes about 9% ($8.3 billion) to the total costs for all OA. About 51% of job related costs result from medical costs and 49% from lost productivity at work and at home. These costs are likely to underestimate the true burden since costs of pain and suffering as well as costs to family members and others who provide home care are ignored. CONCLUSION: The cost of job related arthritis is significant and has implications for both clinical and public policy. Depending on the PAR selected, job related arthritis is at least as costly as job related renal and neurological disease combined, and is on a par with the costs of job related chronic obstructive pulmonary disease and all asthma, whether job related or not.

Costs of occupational injuries and illnesses in California.

OBJECTIVES: The purpose of this study was to estimate the annual incidence, the mortality, and the direct and indirect costs associated with occupational injuries and illnesses in California in 1992. To achieve this, we performed aggregation and analysis of national and California data sets collected by the U.S. Bureau of Labor Statistics, California Workers' Compensation Insurance Rating Bureau, California Division of Industrial Relations, the National Center for Health Statistics, and the U.S. Health Care Financing Administration. METHODS: To assess incidence of and mortality from occupational injuries and illnesses, we reviewed data from state and national surveys and applied an attributable risk proportion method. To assess costs, we used the cost-of-illness, human capital, method that decomposes costs into direct categories such as medical expenses and insurance administration expenses as well as indirect categories such as lost earnings, lost home production, and lost fringe benefits. Some cost estimates were drawn from California data, whereas others were drawn from a national study but were adjusted to reflect California's differences. Cost estimates for injuries were calculated by multiplying average costs by the number of injuries. For the majority of diseases, cost estimates relied on the attributable risk proportion method. RESULTS: Approximately 660 job-related deaths from injury, 1.645 million nonfatal injuries, 7,079 deaths from diseases, and 0.133 million illnesses are estimated to occur annually in the civilian California workforce. The direct ($7.04 billion, 34%) plus indirect ($13.62 billion, 66%) costs were estimated to be $20.7 billion. Injuries cost $17.8 billion (86%) and illnesses $2.9 billion (14%). These estimates are likely to be low because: (1) they ignore costs associated with pain and suffering, (2) they ignore home care provided by family members, and (3) the numbers of occupational injuries and illnesses are likely to be undercounted. CONCLUSION: Occupational injuries and illnesses are a major contributor to the total cost of health care and lost productivity in California. These costs are on a par with those of all cancers combined and only slightly less than the cost of heart disease and stroke in California. Workers' compensation covers less than one-half of the costs of occupational injury and illness.

Costs of occupational injuries in agriculture.

OBJECTIVE: This study was conducted to estimate the costs of job-related injuries in agriculture in the United States for 1992. METHODS: The authors reviewed data from national surveys to assess the incidence of fatal and non-fatal farm injuries. Numerical adjustments were made for weaknesses in the most reliable data sets. For example, the Bureau of Labor Statistics (BLS) Annual Survey estimate of non-fatal injuries is adjusted upward by a factor of 4.7 to reflect the BLS undercount of farm injuries. To assess costs, the authors used the human capital method that allocates costs to direct categories such as medical expenses, as well as indirect categories such as lost earnings, lost home production, and lost fringe benefits. Cost data were drawn from the Health Care Financing Administration and the National Council on Compensation Insurance. RESULTS: Eight hundred forty-one (841) deaths and 512,539 non-fatal injuries are estimated for 1992. The non-fatal injuries include 281,896 that led to at least one full day of work loss. Agricultural occupational injuries cost an estimated $4.57 billion (range $3.14 billion to $13.99 billion) in 1992. On a per person basis, farming contributes roughly 30% more than the national average to occupational injury costs. Direct costs are estimated to be $1.66 billion and indirect costs, $2.93 billion. CONCLUSIONS: The costs of farm injuries are on a par with the costs of hepatitis C. This high cost is in sharp contrast to the limited public attention and economic resources devoted to prevention and amelioration of farm injuries. Agricultural occupational injuries are an underappreciated contributor to the overall national burden of health and medical costs.

Costs of occupational circulatory disease.

This chapter analyzes the overt and hidden economic costs of work-related cardiovascular diseases Affected individuals and society at large, rather than employers, pay much of the costs. Economic interventions to motivate public health approaches to preventing CVD are explored.

Hazards for nearby residents and cleanup workers of waste sites.

This study weighs the risks to workers of cleaning up Superfund sites against the risks to residents if the sites were not cleaned up. Risks are measured by the number of deaths and disabilities due to injuries and diseases, as well as by the costs of these deaths and disabilities. We posit three methods to clean up the sites: one that is labor-intensive and two that are not. We posit 24 hypothetical sites, with varying numbers of residents and levels of cancer death and cancer disability rates. Depending on the cleanup method, the number of residents, and the rates, we find that the risks to workers frequently outweigh the risks to residents. We conclude that risks to workers should be accounted for in Environmental Protection Agency judgments regarding which and how Superfund sites should be cleaned up.

Longterm health outcomes of patients with rheumatoid arthritis treated in managed care and fee-for-service practice settings.

OBJECTIVE: To compare health care utilization and longterm health outcomes among patients with rheumatoid arthritis (RA) treated in managed care and fee-for-service practice settings. METHODS: We compared levels of health care utilization, treatments, and health outcomes between 57 patients with RA treated predominantly in managed care settings and 125 patients with RA treated predominantly in fee-for-service practice settings. These patients were participants in a community based cohort study of health outcomes in RA, and had been followed prospectively for up to 13 years (mean followup 10.3 yrs). Information on physician visits, hospitalizations, diagnostic testing, treatments, and 3 measures of health status (global arthritis status, pain, functional disability measures of the Health Assessment Questionnaire) was collected using biannual mailed questionnaires. RESULTS: All measures of health care utilization were similar between the managed care and fee-for-service groups, as was the use of the major types of arthritis treatments. Average global arthritis status scores, pain scores, and functional disability scores were closely comparable in the 2 groups. Over time, global arthritis status scores and disability scores worsened in both groups, but the rates of worsening did not differ between groups. CONCLUSION: In this cohort, longterm health outcomes, as well as treatments and health care utilization, were similar among persons with RA who were treated in managed care and fee-for-service practice settings.

Job-related diseases and occupations within a large workers' compensation data set.

The objective of this report is to describe workers' job-related diseases and the occupations associated with those diseases. The methods include aggregation and analysis of job-related disease and occupation data from the Bureau of Labor Statistics' Supplementary Data System (SDS) for 1985 and 1986--the last years of data available with workers' compensation categories: death, permanent total, permanent partial, and temporary total and partial. Diseases are ranked according to their contribution to the four workers' compensation (WC) categories and also ranked within occupations according to the number of cases. Occupations are ranked according to their contribution to specific diseases within one of the four categories. The following diseases comprise the greatest numbers of deaths: heart attacks, asbestosis, silicosis, and stroke. Within the permanent total category, the diseases with the greatest contributions are heart attack, silicosis, strokes, and inflammation of the joints. For the permanent partial category, they are hearing loss, inflammation of joints, carpal tunnel syndrome, and heart attacks. For the temporary total and partial category, they are: inflammation of joints, carpal tunnel syndrome, dermatitis, and toxic poisoning. Hearing loss or inflammation of joints are associated with more than 300 occupations. Circulatory diseases comprise a larger share of job-related diseases than is generally acknowledged. Occupations contributing the most heart attack deaths are truck drivers, managers, janitors, supervisors, firefighters, and laborers. Ratios of numbers of deaths to numbers of disabilities are far higher for illnesses than injuries. Occupations that are consistent in their high ranking on most lists involving a variety of conditions include nonconstruction laborers, janitors, and construction laborers. The large SDS, though dated, provides a tentative national look at the broad spectrum of occupational diseases as defined by WC and the occupations associated with those diseases in 1985 and 1986. Some description of the spectrum of diseases encountered today is possible especially for occupations, such as those mentioned above for which employment has expanded in the 1990s.

Occupational illnesses within two national data sets.

To describe occupational illness data in two large data sets, two national data sets were aggregated, and the numbers, percentages, and rates of cases of occupational illnesses were determined. Job-related illness data were from Bureau of Labor Statistics documents containing Annual Survey and Census of Fatal Occupational Injury data. A severity index was created to assess the overall burden of a disease. The index multiplies the number of cases times the median days lost. Circulatory disease accounted for 85% of the deaths in the Census and at least 80% in the Annual Survey. More fatal myocardial infarctions occurred on Monday than on any other day. Low-paying occupations had the most myocardial infarctions: operators, laborers, and truck drivers; high-paying occupations had the least: executives, administrators, and managers. Carpal tunnel syndrome and hearing loss accounted for more morbidity, measured by cases and days lost, than any other illness. Persons at great risk for carpal tunnel syndrome included dental hygienists, butchers, sewing machine operators, and dentists. Mental disorders generated more morbidity than is generally acknowledged. Neurotic reactions to stress were highest in the transportation and public utility industries, as well as in finance, insurance, and real estate. Manufacturing contributed far more cases than any other industry. Industries generating significant asbestos-related deaths included construction and boat building. Ninety-three percent of all illness fatalities were among men. Few African Americans died from coal-workers' pneumoconiosis. Illness cases increased much faster than injury cases in recent years. The two data sets provide insights into the incidences and prevalences of occupational illnesses, but underestimate the burden of job-related illnesses.

Medical costs in workers' compensation insurance: comment.

Professors Baker and Krueger ignore some costs associated with workers' compensation. Because of these costs, the contention that physicians willfully exploit the workers' compensation system for their own gain is questioned.

Occupational injury and illness in the United States. Estimates of costs, morbidity, and mortality.

OBJECTIVE: To estimate the annual incidence, the mortality and the direct and indirect costs associated with occupational injuries and illnesses in the United States in 1992. DESIGN: Aggregation and analysis of national and large regional data sets collected by the Bureau of Labor Statistics, the National Council on Compensation Insurance, the National Center for Health Statistics, the Health Care Financing Administration, and other governmental bureaus and private firms. METHODS: To assess incidence of and mortality from occupational injuries and illnesses, we reviewed data from national surveys and applied an attributable risk proportion method. To assess costs, we used the human capital method that decomposes costs into direct categories such as medical and insurance administration expenses as well as indirect categories such as lost earnings, lost home production, and lost fringe benefits. Some cost estimates were drawn from the literature while others were generated within this study. Total costs were calculated by multiplying average costs by the number of injuries and illnesses in each diagnostic category. RESULTS: Approximately 6500 job-related deaths from injury, 13.2 million nonfatal injuries, 60,300 deaths from disease, and 862,200 illnesses are estimated to occur annually in the civilian American workforce. The total direct ($65 billion) plus indirect ($106 billion) costs were estimated to be $171 billion. Injuries cost $145 billion and illnesses $26 billion. These estimates are likely to be low, because they ignore costs associated with pain and suffering as well as those of within-home care provided by family members, and because the numbers of occupational injuries and illnesses are likely to be undercounted. CONCLUSIONS: The costs of occupational injuries and illnesses are high, in sharp contrast to the limited public attention and societal resources devoted to their prevention and amelioration. Occupational injuries and illnesses are an insufficiently appreciated contributor to the total burden of health care costs in the United States.

Public and private workers' compensation insurance.

Utilizing unique data from the federal government's Social Security office, we analyze the costs of providing workers' compensation by public vs private insurers. Our analysis has the advantage that public and private recipients are likely to be more similar than public (Medicare, Medicaid) and private recipients of health insurance in the US or Canadian economies. We find that public firms appear to provide workers' compensation insurance more efficiently than private firms.

Ranking occupations based upon the costs of job-related injuries and diseases.

In this article, we construct a ranking of occupations based upon the costs of job-related injuries and illnesses. Data are drawn from large nationally representative Bureau of Labor (BLS) data sets. Information is obtained on occupation and workers' compensation (WC) category of the injury or illness, which are then matched to information on costs. Six broad occupations and 413 specific (3-digit) occupations are ranked by total costs. Six broad and 223 specific occupations are ranked by costs per worker (average cost). Operators and laborers is the broad occupation category that contributes both the highest total and average cost. Specific occupations that contributed the most to total costs include heavy truck drivers, non-construction laborers, machine operators (not specified), occupations not classified, janitors, nursing orderlies, construction laborers, assemblers, retail sales workers (not elsewhere specified), miscellaneous machine operators, and carpenters. Occupations high on the average cost list include not-specified mechanics, general and construction laborers, press apprentices, welders, stone cutters, and warehouse workers. Although the BLS data are limited, they can be used to provide a preliminary look at which occupations are contributing the most and the least to the overall economic costs of occupational injuries and illnesses.

Occupations, cigarette smoking, and lung cancer in the epidemiological follow-up to the NHANES I and the California Occupational Mortality Study.

What jobs are associated with the highest and lowest levels of cigarette use and of lung cancer? Are there gender differences in these jobs? Two data sets-the Epidemiological Follow-up to the National Health and Nutrition Examination Survey (NHEFS) and the California Occupational Mortality Study (COMS) were analyzed to answer these questions. For females, the broad occupations ranking from highest to lowest cigarette use in the NHEFS was: transportation operators, managers, craft workers, service workers, operatives, laborers, technicians, administrative workers, farm owners and workers, sales workers, no occupation, and professionals. The corresponding ranking for males was: transportation operators, no occupation, laborers, craft workers, service workers, technicians, and professionals. The highest-ranking jobs in the COMS were waitresses, telephone operators, and cosmetologists for women, and water-transportation workers, roofers, foresters and loggers for men. Teachers were especially low on all four lists. This study could not determine whether employment within any occupation encouraged smoking or if smokers selected certain occupations.

Potential and actual workdays lost among patients with HIV.

How many more potential and actual workdays are lost by HIV patients than persons without HIV? To answer this question, we assessed differences in the number of workdays among a panel of AIDS patients, patients who were HIV positive but did not yet have AIDS, and comparison patients. The patients included persons who were employed and unemployed. Information on 1,346 patients was gathered from January 1, 1990, to December 31, 1992, as part of the ongoing ATHOS (AIDS Time-Oriented Health Outcome Study) study. Data were collected every 3 months on AIDS and HIV-positive patients and every 6-12 months on the comparison patients. At the end of the study (December 31, 1992), 856 people were still enrolled. A total of 5,507 panel data points covering 3 years were available. Data were analyzed with a linear regression model. We found that patients with AIDS reported 29-32 and HIV-positive patients reported 9-13 more potential and actual workdays lost out of the previous 90 than the comparison patients, other variables being equal. All p values were < 0.005, and most were < 0.0001. We conclude that (a) while the AIDS patients showed substantially more workdays lost than the comparison group, the HIV-positive group showed only a modest number of more days lost than the comparison group and (b) that previous estimates exaggerated indirect morbidity costs.

Hours at work and employment status among HIV-infected patients.

OBJECTIVE: To study differences in employment and work hours among three groups of HIV-infected and non-infected individuals. METHODS: Data on 1263 patients seen in five different sites in California were drawn from the AIDS Time-Oriented Health Outcome Study. Three groups of patients were examined: AIDS patients, HIV-positives without diagnosed AIDS, and HIV-negatives. The HIV-negative patients were used as a comparison group in comparing hours worked by all patients, whether they worked or not; the probability of working, regardless of the number of hours; and work hours only for those patients who worked. RESULTS: Adjustment for covariates in a 2-equation econometric model reduced the difference in employment rates between the AIDS patients and the other two groups, suggesting that characteristics other than AIDS status account, in part, for their low employment rates. After adjustment, we did not find any statistically significant differences in employment probabilities or work hours between the HIV-positive patients without diagnosed AIDS and the comparison group. However, AIDS patients reported approximately 14 work hours fewer (P < 0.0001) and lower probabilities of employment (P < 0.0001) than the HIV-negative comparison group among all patients with and without jobs. Moreover, among those with jobs, patients with AIDS reported approximately 3 work hours fewer per week (P = 0.0385). No statistically significant differences in work hours were found between HIV-positives without diagnosed AIDS and comparison patients. CONCLUSION: AIDS patients were less likely to be employed than either of the other groups, but crude, unadjusted unemployment rates exaggerate the effect of AIDS. For those employed, AIDS patients work only 3 h less per week than either of the other groups.

Dangerous jobs and heavy alcohol use in two national probability samples.

Samples of employed persons within the US were drawn from the National Health and Nutrition Examination Survey II (n = 8477), and the Quality of Employment Survey (n = 1393) to test the hypothesis that a positive association existed between alcohol use and job hazards. Heavy total alcohol use, or beer or wine or liquor use separately, were the dependent variables. The key independent variables included subjects' evaluations of hazardous nature of the job and fatality rates within occupations and industries. Models were estimated with logistic regressions controlling for age, gender, race and other covariates. Only one robust finding emerged: heavy beer use was found to be positively and strongly correlated with the fatality rate within occupations. Additional correlations between job hazards and heavy alcohol use were weak, generated large P values, and some suggested an inverse association. The lack of robust findings for the additional correlations may partially be explained by the associations between job categories on the one hand and choice of beverage on the other. Blue-collar jobs are more hazardous than white-collar jobs, on average. Persons in blue-collar jobs were more likely to drink beer, while those in white-collar jobs were more likely to drink wine or liquor (spirits). Separate analyses of beer, wine and liquor appeared essential to explaining correlations between dangerous jobs and heavy alcohol use in these data. Limitations of the study included (1) age of the data (from the 1970s). (2) alcohol use and some job hazards were measured by self-report, and (3) data were from only one country.

Estimated risk of occupational fatalities associated with hazardous waste site remediation.

This study presents a method to assess short term traumatic fatality risks for workers involved in hazardous waste site remediation to provide a quantitative, rather than qualitative, basis for evaluating occupational exposures in remediation feasibility studies. Occupational employment and fatality data for the years 1979-1981 and 1983 were compiled from Bureau of Labor Statistics data for 11 states. These data were analyzed for 17 occupations associated with three common remediation alternatives: excavation and landfill, capping, and capping plus slurry wall. The two occupations with the highest death rates, truck driver and laborer, contributed most to total exposure hours in each alternative. Weighted average death rates were produced for each alternative and multiplied by respective total person-years of exposure. The resultant expected number of fatalities was converted, using the Poisson distribution, to the risk of experiencing at least one fatality, as follows: 0.149 for excavation and landfill, 0.012 for capping, and 0.014 for capping plus slurry wall. These risks were discussed in light of the need to obtain more reliable and comprehensive data than are currently available on the occupational safety and health risks associated with hazardous waste site remediation and the need for a more scientific, quantitative approach to remediation decisions involving risks to workers.