A risk-based system to penalize and reward line management for occupational safety and health performance. (33/934)

Penalizing line management for the occurrence of lost time injuries has in some cases had unintended negative consequences. These are discussed. An alternative system is suggested that penalizes line management for accidents where the combination of the probability of recurrence and the maximum reasonable consequences such a recurrence may have exceeds an agreed limit. A reward is given for prompt effective control of the risk to below the agreed risk limit. The reward is smaller than the penalty. High-risk accidents require independent investigation by a safety officer using analytical techniques. Two case examples are given to illustrate the system. Continuous safety improvement is driven by a planned reduction in the agreed risk limit over time and reward for proactive risk assessment and control.  (+info)

Do GPs sick-list patients to a lesser extent than other physician categories? A population-based study. (34/934)

BACKGROUND: Large differences between physicians in their use of the sickness certification instrument have been described. There are also indications of differences between different categories of physicians, for instance that occupational health physicians and GPs are less generous with certificates of long duration. OBJECTIVES: We therefore decided to test the hypothesis that GPs and occupational health physicians issue more short-term certificates and use partial sick-listing more often than other physicians. METHODS: Certificates for sickness absence during 4 months in 1995 and 2 months in 1996 were collected in eight Swedish counties; a total of 57 563 certificates. From the certificates, a number of variables were extracted. RESULTS: Sickness certificates issued by GPs were on average for a shorter period of time than those issued by other physicians, for the individual certificate as well as for the total sickness period. Occupational health physicians had longer certification periods than GPs but used partial sick-listing more frequently. However, the patients of the various categories of physicians differed regarding age, sex, diagnosis distribution, etc. When the influence of these factors on the duration of the certification periods was taken into account, the GPs still issued significantly shorter periods of sick-leave than the other physicians, followed by the occupational health physicians. CONCLUSIONS: The results may be indicative of a different way of handling the sickness certification instrument among different categories of physicians, especially GPs.  (+info)

The cost of long term therapy for gastro-oesophageal reflux disease: a randomised trial comparing omeprazole and open antireflux surgery. (35/934)

BACKGROUND AND AIM: To comprehensively assess the relative merits of medical and surgical therapy for gastro-oesophageal reflux disease (GORD), health economic aspects have to be incorporated. We have studied the direct and indirect costs of medical and surgical therapy within the framework of a prospective randomised multicentre trial. METHODS: After initial treatment of reflux oesophagitis with omeprazole to control symptoms and to heal oesophagitis, 154 patients were randomised to continue treatment with omeprazole (20 or 40 mg daily) and 144 patients to have an open antireflux operation (ARS). In case of GORD relapse, patients allocated to omeprazole were offered ARS and those initially operated on had either a reoperation or were treated with omeprazole. The costs were assessed over five years from randomisation. RESULTS: Differences in cumulative direct medical costs per patient between the two therapeutic strategies diminished with time. However, five year direct medical costs per patient when given omeprazole were still significantly lower than for those having ARS in Denmark, Norway, and Sweden (differences were DKK 8703 (US$1475), NOK 32 992 (US$ 5155), and SEK 13 036 (US$ 1946), respectively). However, in Finland the reverse was true (the difference in favour of ARS amounted to FMK 7354 (US$ 1599)). When indirect costs (loss of production due to GORD related sick leave) were also included, the cost of surgical treatment increased substantially and exceeded the cost of medical treatment in all countries. CONCLUSIONS: The total costs of medical therapy for chronic GORD were lower than those of open ARS when prospectively assessed over a five year period, although significant differences in cost estimates were revealed between countries.  (+info)

The role of radiography in primary care patients with low back pain of at least 6 weeks duration: a randomised (unblinded) controlled trial. (36/934)

OBJECTIVES: To test the hypotheses that: (1) Lumbar spine radiography in primary care patients with low back pain is not associated with improved patient outcomes, including pain, disability, health status, sickness absence, reassurance, and patient satisfaction or belief in the value of radiography. (2) Lumbar spine radiography in primary care patients with low back pain is not associated with changes in patient management, including medication use, and the use of primary and secondary care services, physical therapies and complementary therapies. (3) Participants choosing their treatment group (i.e. radiography or no radiography) do not have better outcomes than those randomised to a treatment group. (4) Lumbar spine radiography is not cost-effective compared with usual care without lumbar spine radiography. DESIGN: A randomised unblinded controlled trial. SETTING: Seventy-three general practices in Nottingham, North Nottinghamshire, Southern Derbyshire, North Lincolnshire and North Leicestershire. Fifty-two practices recruited participants to the trial. SUBJECTS: Randomised arm: 421 participants with low back pain, with median duration of 10 weeks. Patient preference arm: 55 participants with low back pain, with median duration of 11 weeks. INTERVENTION: Lumbar spine radiography and usual care versus usual care without radiography. MAIN OUTCOME MEASURES: Roland adaptation of the Sickness Impact Profile, visual analogue pain scale, health status scale, EuroQol, use of primary and secondary care services, and physical and complementary therapies, sickness absence, medication use, patient satisfaction, reassurance and belief in value of radiography at 3 and 9 months post-randomisation. RESULTS: Participants randomised to receive an X-ray were more likely to report low back pain at 3 months (odds ratio (OR) = 1.56; 95% confidence interval (CI), 1.02 to 2.40) and had a lower overall health status score (p = 0.02). There were no differences in health or functional status at 9 months. A higher proportion of participants consulted the general practitioner (GP) in the 3 months following an X-ray (OR = 2.72; 95% CI, 1.80 to 4.10). There were no differences in use of any other services, medication use or sickness absence at 3 or 9 months. No serious spinal pathology was identified in either group. The commonest X-ray reports were of discovertebral degeneration and normal findings. Many patients did not perceive their information needs were met within the consultation. Satisfaction with care was greater in the group receiving radiography at 9 months. Participants randomised to receive an X-ray were not less worried, or more reassured about serious disease causing their low back pain. Satisfaction was associated with meeting participants' information needs and reduced belief in the necessity for investigations for low back pain, including X-rays and blood tests. In both groups, at 3 and 9 months 80% of participants would choose to have an X-ray if the choice was available. Participants in the patient preference group achieved marginally better outcomes than those randomised to a treatment group, but the clinical significance of these differences is unclear. Lumbar spine radiography was associated with a net economic loss at 3 and 9 months. CONCLUSIONS: Lumbar spine radiography in primary care patients with low back pain of at least 6 weeks duration is not associated with improved functioning, severity of pain or overall health status, and is associated with an increase in GP workload. Participants receiving X-rays are more satisfied with their care, but are not less worried or more reassured about serious disease causing their low back pain. CONCLUSIONS - RECOMMENDATIONS FOR FURTHER RESEARCH: Further work is required to develop and test an educational package that educates patients and GPs about the utility of radiography and provides strategies for identifying and meeting the information needs of patients, and the needs of patients and GPs to be reassured about missing serious disease. Guidelines on the management of low back pain in primary care should be consistent about not recommending lumbar spine radiography in patients with low back pain in the absence of red flags for serious spinal pathology, even if the pain has persisted for at least 6 weeks.  (+info)

Organisational downsizing and musculoskeletal problems in employees: a prospective study. (37/934)

OBJECTIVES: To study the association between organisational downsizing and subsequent musculoskeletal problems in employees and to determine the association with changes in psychosocial and behavioural risk factors. METHODS: Participants were 764 municipal employees working in Raisio, Finland before and after an organisational downsizing carried out between 1991 and 1993. The outcome measures were self reports of severity and sites of musculoskeletal pain at the end of 1993 and medically certified musculoskeletal sickness absence for 1993-5. The contribution of changes in psychosocial work characteristics and health related behaviour between the 1990 and 1993 surveys was assessed by adjustment. RESULTS: After adjustment for age, sex, and income, the odds ratio (OR) for severe musculoskeletal pain between major and minor downsizing and the corresponding rate ratios for musculoskeletal sickness absence were 2.59 (95% confidence interval (95% CI) 1.5 to 4.5) and 5.50 (3.6 to 7.6), respectively. Differences between the mean number of sites of pain after major and minor downsizing was 0.99 (0.4 to 1.6). The largest contribution from changes in work characteristics and health related behaviour to the association between downsizing and musculoskeletal problems was from increases in physical demands, particularly in women and low income employees. Additional contributory factors were reduction of skill discretion (relative to musculoskeletal pain) and job insecurity. The results were little different when analyses were confined to initially healthy participants. CONCLUSIONS: Downsizing is a risk factor for musculoskeletal problems among those who remain in employment. Much of this risk is attributable to increased physical demands, but adverse changes in other psychosocial factors may also play a part.  (+info)

The role of extended weekends in sickness absenteeism. (38/934)

OBJECTIVES: Employees are thought to lengthen their weekends by voluntary absenteeism, but the magnitude of such potentially reversible behaviour is not known. METHODS: A follow up study based on employers' registers on the dates of work contracts and absences in 27 541 permanent full time municipal employees in five towns during 1993-7. The absence rate on each weekday separately for all sick leaves and for 1 day sick leaves was determined. RESULTS: 3.4% of the male employees and 5.0% of the female employees were on sick leave daily. The mean rate of sickness absence was lowest on Mondays, after which it increased towards Wednesday, and remained on the same level for the rest of the week. This pattern applied to both sexes, to each year of the follow up, and across towns, age groups, and income groups. For 1 day sick leaves, representing 4.5% of the total sickness absenteeism, the rates of sick leave for Mondays and Fridays were 1.4 and 1.9 times greater than those for other weekdays. However, these excess rates account for less than 1% of all days lost due to sickness absenteeism. Extended weekend absences were more common in men, in young employees, and in those in a low socioeconomic position, and they varied between towns. CONCLUSION: Extended weekends seem to contribute only marginally to the days lost due to sickness absenteeism.  (+info)

Backache in gynaecologists. (39/934)

The objectives of the study were to assess the overall prevalence of backache in gynaecologists and determine its impact on work, and to identify possible occupational risk factors. The sample comprised gynaecologists, both active and retired, listed as members of the Ulster Obstetrical and Gynaecological Society, who were asked to complete and return a postal questionnaire. The response rate was 94% (107/114). The prevalence of backache, which included pain arising in the thoracic and lumbosacral regions, was 72%. Fifty-three per cent of those with back pain blamed it on working in obstetrics and gynaecology. Overall, 32% of gynaecologists required a change of their work practice, 20% had taken time off work and 8% had required surgery. We conclude that significant morbidity results from backache in gynaecologists. This has economic implications and requires further assessment to improve prevention, with emphasis on individual training and ergonomic evaluation of work-related postures.  (+info)

Laparoscopic cholecystectomy versus mini-laparotomy cholecystectomy: a prospective, randomized, single-blind study. (40/934)

OBJECTIVE: To analyze outcomes after open small-incision surgery (minilaparotomy) and laparoscopic surgery for gallstone disease in general surgical practice. METHODS: This study was a randomized, single-blind, multicenter trial comparing laparoscopic cholecystectomy (LC) to minilaparotomy cholecystectomy (MC). Both elective and acute patients were eligible for inclusion. All surgeons normally performing cholecystectomy, both trainees under supervision and consultants, operated on randomized patients. LC was a routine procedure at participating hospitals, whereas MC was introduced after a short training period. All nonrandomized cholecystectomies at participating units during the study period were also recorded to analyze the external validity of trial results. The randomization period was from March 1, 1997, to April 30, 1999. RESULTS: Of 1,705 cholecystectomies performed at participating units during the randomization period, 724 entered the trial and 362 patients were randomized to each of the procedures. The groups were well matched for age and sex, but there were fewer acute operations in the LC group than the MC group. In the LC group 264 and in the MC group 150 operations were performed by surgeons who had done more than 25 operations of that type. Median operating times were 100 and 85 minutes for LC and MC, respectively. Median hospital stay was 2 days in each group, but in a nonparametric test it was significantly shorter after LC. Median sick leave and time for return to normal recreational activities were shorter after LC than MC. Intraoperative complications were less frequent in the MC group, but there was no difference in the postoperative complication rate between the groups. There was one serious bile duct injury in each group, but no deaths. CONCLUSIONS: Operating time was longer and convalescence was smoother for LC compared with MC. Further analyses of LC versus MC are necessary regarding surgical training, surgical outcome, and health economy.  (+info)