By Karen O’Hara
The National Institute for Occupational Safety and Health (NIOSH)is being urged to place a higher priority on research to help prevent work-related injuries and illnesses from unnecessarily becoming chronic disabling conditions.
In a Feb. 9, 2015, letter addressed to NIOSH officials, Gary M. Franklin, M.D., M.P.H., medical director, Washington Department of Labor And Industries, and Kathryn Mueller, M.D., M.P.H., president, American College of Occupational and Environmental Medicine (ACOEM), write:
“We believe secondary prevention requires serious consideration for substantially increased research funding. Although preventing injuries is an essential activity of NIOSH, preventing worker disability should also hold a prominent position. With increasing pressure on Social Security Disability Insurance (SSDI), it is essential that U.S. workers ‘ productivity for those who have been injured on the job be maintained and disability prevented.”
In this context, secondary prevention may be defined as early diagnosis and treatment of work-related injuries and illnesses to facilitate safe return to work, recovery, and full function.
Workplace wellness programs that encourage healthy behaviors such as regular exercise and not smoking are examples of primary prevention strategies designed to stop a disease or condition from occurring in the first place. Tertiary prevention deals with managing an existing disease or condition to reduce its impact, such as controlling
diabetes or asthma.
Proponents cite a number of reasons for an increased commitment to secondary prevention research:
• The majority of workers who develop persistent low-back pain and other chronic conditions initially experience injuries that were not considered serious at the outset.
• Studies show factors other than the injury itself contribute to a scenario in which about 80 percent of related workers’ compensation costs are attributed to only about five percent of injured employees in the U.S.
• Productivity loss is measured in years not weeks or months lived with disability.
(http://jama.jamanetwork.com/article.aspx?articleID=1710486)
• The nation’s Social Security system is sagging under the weight of disability-related costs.
BURDENS ON SOCIETY
Morbidity and chronic disability account for nearly half of the health burden in the U.S. Related medical, legal, and benefits costs, lost productivity and diminished quality of life are liabilities borne by all citizens. Mental and behavioral disorders, musculoskeletal complaints, vision and hearing loss, anemias, and neurological conditions all contribute to increases in chronic disability. Three of the top five conditions accounting for the most Years Lived with Disability (YLD) in the U.S. in 2010 were:
- back (3.18 million YLD)
- other musculoskeletal (2.6 million YLD)
- neck (2.13 YLD) conditions
Anxiety and depression accounted for the other two of the top five conditions.
The most consistently reported early predictors of persistent disability after the onset of low-back pain are a high degree of pain interference with the ability to work, psychosocial variables such as high fear avoidance and catastrophizing, low expectations of a return to work, and employer factors including no offer of work accommodation.
Aging and increasing rates of obesity, hypertension, and diabetes in the working population are also factors that contribute to longer recovery times and the potential for long-term disability. Disability originating in federal and state workers’ compensation systems often finds its way into the SSDI system. For example, nearly a third of all SSDI recipients have musculoskeletal disorders many of them attributed to a work injury. In the Washington state workers compensation system, more than nine percent of compensable claims initiated in 2007 now appear to be headed for a permanent disability designation, Drs. Franklin and Mueller report. In their letter to NIOSH, they suggest that workers’ compensation claims and related data be used to identify strategies that contribute to decreased disability for injured workers and help direct “meaningful interventions for increasing secondary prevention.”
RESEARCH OBJECTIVES
At a meeting of workers’ compensation and occupational health leaders, in December 2014, Drs. Franklin and Mueller said a number of stakeholders suggested secondary prevention research should be in the hands of insurers and others who possess related data.“The problem,” they said, “is that neither the research nor capacity to use data in meaningful ways resides [with] most insurers.
In addition, from many years of experience using Washington State workers’ compensation data for secondary prevention research, we believe it will take substantial research incentives to do so.“Both physicians have considerable expertise in this area. Dr. Franklin Is a research professor in the Department of Environmental and Occupational Health Sciences at the University of Washington, Seattle, and a board-certified neurologist.
His research interests include the use of workers’ compensation data to study musculoskeletal treatment outcomes, predictors of disability, and the impact of care delivery systems cost, outcome, and satisfaction. Dr.Mueller is a professor in the Colorado School of Public Health and medical director of the Colorado Division of Workers Compensation. She is nationally recognized for her role in the development of evidence-based treatment guidelines and knowledge of disability assessment and impairment rating methodology.
With sufficient funding, they suggest secondary prevention research could focus on three areas:
1. Summarizing scientific evidence that has already meaningfully contributed to secondary prevention in workers’ compensation systems, including:
- modifiable and other risk factors for disability
- screening tools to identify workers at greatest risk of developing long-term disability within two-to-six weeks of the first report of injury
- best practices and health system changes that show promise in preventing disability
- evaluating research on return to work after an occupational injury
2. Identifying systems and changes in delivery models that have shown promise in secondary prevention of disability and analyzing contributors to disability including overuse of opioid prescription medications, potentially harmful procedures such as spinal fusion and thoracic outlet surgery, and prolonged physical therapy.
3. Investigating methods to prevent the transition from acute and subacute (musculoskeletal) pain to chronic pain, recognizing that chronic pain is typically concurrent with the development of disability in workers’ compensation cases.
“Following the identification of promising approaches to preventing disability, NIOSH, either alone or in collaboration with other institutes, could promote intervention trials to reduce disability in the workplace. These trials would engage NIOSH with employers, workers, and workers’ compensation insurers in a common mission,” Drs. Franklin and Mueller say in their letter to NIOSH DirectorJohn Howard, M.D., and Dr. SteveWurzelbacher, director of the Center For Workers’ Compensation Studies.“NIOSH has not yet worked up a formal response to the letter,” Dr.Wurzelbacher reported in early March, partly because the agency is awaiting receipt of draft proceedings from the December meeting.NIOSH does not have an estimate of funding allocated toward secondary-
prevention research, “ but can look at the system,” he added. “It is a bit difficult because there are many related projects, such as ergonomics, that overlap with secondary/tertiary prevention but are not necessarily coded as such.”
FUNDING CHALLENGES
The doctors’ request comes at a time when overall funding for NIOSH is threatened. The Obama Administration has proposed eliminating funding for NIOSH’s Education and Research (ERCs) and its Agriculture, Forestry, and Fishing (AFF) program for the FY 2016 budget presented to Congress earlier this year. The Proposal represents a 15 percent cut in NIOSH’s budget, which would total $283 million. In another letter sent earlier this year to congressional leaders, Friends of NIOSH – a coalition of industry, labor, professional, educational, and scientific organizations – urged Congress to maintain funding for ERCs and the program, saying their elimination“would limit the ability of workers to avoid exposures that can result in injury or illnesses, push back improved working conditions and eliminate occupational safety and health educational services to over 10,000 U.S. businesses, and ultimately raise healthcare costs.”Previous bids to eliminate ERC and AFF funding have also been met with protests from the occupational health and safety community.
By comparison, under the FY 2016 budget proposal, the Occupational Safety and Health Administration(OSHA), the government’s enforcement arm, would receive more than $592 a million – an increase of more than $39.2 million compared to FY 2015. Federal enforcement funding would be increased by $17.6 million, for a total of $225.6 million.
The American Industrial Hygiene Association’s Government Affairs Director Aaron Trippler reports that the largest increase would go to whistleblower programs, which would get an additional $ 5.1 million (about a 30 percent increase). But Mr. Trippler warned that it’s too soon to draw any conclusions: “We haven’t even had a real budget the last few years, simply an omnibus bill.”
PREVENTION ORIENTATION
Given that certification in occupational medicine is awarded to physicians by the American Board of Preventive Medicine, an orientation toward population-based health management is to be expected. While clinical care usually addresses the needs of an individual, public health deals with groups of people, such as workers in a certain type of industry or location. Primary, secondary, and tertiary prevention can be delivered at the population level, according to the Centers for Disease Control and Prevention (CDC).
Many physicians who practice occupational medicine dedicate time to evaluating workplace hazards, analyzing population health trends, and making recommendations on preventive health interventions. However, while some employers have embraced evidence that suggests preventive programs result in savings and improved quality of life, others remain unimpressed with return-on-investment scenarios and are reluctant to make significant investments in prevention efforts.
Meanwhile, workers continue to get hurt on the job while occupational health programs and clinics depend on revenue generated from injury and illness treatment and management activities. The Reality is that prevention-minded doctors frequently find themselves engaged in secondary prevention which in turn helps employers recognize that delayed recovery can be anticipated and disability prevented in the majority of workers’ compensation cases.”
RECOMMENDATIONS
One of the positive outcomes of secondary prevention research would be the validation of measures that address“medicalization;” i.e., the process in which non-medical, psychosocial issues become defined and treated as medical problems. While waiting for definitive findings from scientific research, employers and other stakeholders in the workers’ compensation system are advised to:
- Work with qualified occupational health professionals who are prepared to address disability warning signs such as depression, poor performance, frequent absences, and interpersonal relationship or financial problems.
- Arrange for appropriate medical guidance to be provided as early as possible after an injury to educate employees about their condition, evaluate self-care measures, and establish realistic expectations for recovery.
- Advocate for a collaborative, cross-disciplinary approach to help minimize the impact of injury, illness, impairment, and aging on employees so they can be functional, productive, and enjoy their lives.
- Develop comprehensive on-the-job recovery and transitional work programs that support return to work and early mobility.
- Tap into human resources expertise; studies show workplace issues such as poor job fit and not getting along with one’s supervisor contribute to disability mindset.
- Encourage the use of behavioral health and employee assistance programs (EAPs)
In addition, experts say employers and others who recognize the power of intersecting conditions and processes are more likely to experience corresponding declines in long-term disability claims. Influencing factors include an injured employee’s apparent coping skills resiliency and access to qualified medical professionals.
Washington, a monopolistic workers’ compensation state, is providing a model for other jurisdictions. It is attempting to improve access to quality care by establishing a statewide provider network, and it is the first state to authorize the removal of physicians who have caused harm to injured workers.
“These steps demonstrate the type of commitment that may be needed to make a meaningful improvement in the performance of workers’ compensation programs,” Dr. Franklin and his colleagues say in an article published in the American Journal of Industrial Medicine.
(http://onlineli-brary.wiley.com/doi/10.1002/ajim.22399/full)
Applicable regulations, medical insurance and social welfare benefits, and labor laws including protective provisions contained in the Family and Medical Leave Act and the Americans with Disabilities Act, also play an influential role in outcomes, occupational health professionals say.
REFERENCES
- The State of U.S. Health, 1990-010, Burden of Diseases, Injuries And Risk Factors; JAMA, Vol. 310, No. 6, August 14, 2013. http://jama.jamanetwork.com/article.aspx?articleID=1710486
- Avoiding 10 Common Pitfalls inWork-related Injury Management;Peter P. Greaney, M.D., WorkCare,Inc., 2015; www.workcare.com/education
- Workers’ Compensation: PoorQuality Health Care and the Growing Disability Problem in the UnitedStates (Commentary); G Franklin, et al.; AmJIndMed, Sept.15, 2014;wileyonlinelibrary.com
