Jay S. Himmelstein

The effects of a health promotion-health protection intervention on behavior change: the WellWorks Study

OBJECTIVES This study assessed the effects of a 2-year integrated health promotion-health protection work-site intervention on changes in dietary habits and cigarette smoking. METHODS A randomized, controlled intervention study used the work site as the unit of intervention and analysis; it included 24 predominantly manufacturing work sites in Massachusetts (250-2500 workers per site). Behaviors were assessed in self-administered surveys (n = 2386; completion rates = 61% at baseline, 62% at final). Three key intervention elements targeted health behavior change: (1) joint worker-management participation in program planning and implementation, (2) consultation with management on work-site environmental changes, and (3) health education programs. RESULTS Significant differences between intervention and control work sites included reductions in the percentage of calories consumed as fat (2.3% vs 1.5% kcal) and increases in servings of fruit and vegetables (10% vs 4% increase). The intervention had a significant effect on fiber consumption among skilled and unskilled laborers. No significant effects were observed for smoking cessation. CONCLUSIONS Although the size of the effects of this intervention are modest, on a populationwide basis effects of this size could have a large impact on cancer-related and coronary heart disease end points.

Measuring functional outcomes in work-related upper extremity disorders : Development and validation of the upper extremity function scale

Questionnaire-based measures of function have been validated extensively in studies of chronic illness and work-related low back pain. These measures have only recently been developed for upper extremity disorders (UEDs), and there is little information on their utility in evaluation of injured workers. We developed the Upper Extremity Function Scale (UEFS), an eight-item, self-administered questionnaire, to measure the impacts of UEDs on function. This instrument was tested in a cohort of 108 patients with work-related UEDs and 165 patients with the carpal tunnel syndrome (CTS); both groups were enrolled in prospective follow-up studies. The UEFS demonstrated excellent psychometric properties, including good internal consistency (Cronbachs alpha > 0.83), relative absence of floor effects, and excellent convergent and discriminant validity, compared with measures of symptom severity and clinical findings. In the CTS group, the UEFS was more responsive to significant improvements over time than clinical measures such as grip and pinch strength. These data support the use of a self-reported functional scale as a measure of outcome in studies of work-related UEDs. Further investigations in working populations are needed to substantiate its utility in workers with UEDs who have not yet sought medical care.

Work-related outcomes in occupational low back pain: a multidimensional analysis.

Objectives. This pilot study explored a broad range of work-related outcomes for occupational low back injuries. Methods. A model of occupational outcomes and a survey instrument were developed on the basis of interviews, expert opinion, and literature reviews. New Hampshire workers who had an occupational back injury a year before the study were sampled from first reports of injury and sent a mailed survey about their postinjury experiences and related factors. Results. Of 251 randomly selected cases, a valid address could be identified for 121, and 99 patients responded. Almost 60% of the respondents had lost 1 week of work or more. At 1 year after injury, half of the respondents had returned to their preinjury job and employer, and 20% were unemployed, half of them because of the injury. Most working respondents reported no decrease in their work capacity. However, 68% still had pain exacerbated by work, and 47% worried that their condition would worsen with continued work. Reinjury occurred in 42% of the respondents. The work-related outcome measures were largely independent of each other. Exploratory multivariate analyses demonstrated unique patterns of factors associated with each outcome. Reinjury risk was significantly greater in respondents whose employers offered accommodations or whose postinjury jobs had greater ergonomic risk. The small sample size limited the ability to achieve statistically significant results in multivariate analyses. Conclusions. Simply measuring return to work did not appear to capture the full range of job-related consequences from occupational back injuries in this pilot evaluation. Timing of return to work, occupational ergonomic risks, and appropriate job modifications appeared to be particularly important in a safe return to the job after an occupational low back injury. Results suggest opportunities to address risk factors that may improve work outcomes.

Exposure to Lead from the Mystic River Bridge: The Dilemma of Deleading

City dwellers in the United States are at risk of exposure to lead from numerous sources, including lead-based house paint,1 employment in trades using lead,2 airborne lead from automotive and indu...

Outcomes research: Implications for occupational health

Concerns about quality, cost, and unnecessary medical care have led to substantial interest and growth in outcomes research with studies to determine the full range of effects of disease and comparative effectiveness of treatments. Investigators have developed new conceptual models of health-related quality of life and associated questionnaires, study designs that maximize use of administrative databases and the generalizability of results, and methods to control for severity and co-morbidity. As similar concerns about occupational health care have emerged, these approaches are being adapted for use in the occupational setting, and studies are beginning to address the concerns of working populations. These investigations will require development of new models of outcome, interdisciplinary research teams, adaptation of data collection methods to address the unique concerns of workers and the unique aspects of the workplace, use of new information databases, and methods of analysis. The implications of these concepts for a hypothetical study of carpal tunnel syndrome and a proposed agenda for future studies in occupational health outcomes research are presented.

Occupational upper extremity conditions: a detailed analysis of work-related outcomes.

While work-related upper extremity conditions (WRUECs) cause almost 25% of lost time cases in the US, little is known about their long-term occupational consequences. A self-report survey was mailed to New Hampshire workers reporting a WRUEC one year prior to the study. Of the 72 (52%) valid respondents, 60% had lost ≥1 week of work and 90% had returned to work. Almost 70% reported acute injury onset, and 26% had experienced a recurrence of their WRUEC. Both gradual-onset injuries and recurrences had worse outcomes. Recurrence was related to shorter job tenure, lower job satisfaction, and less satisfaction with medical care and insurer responses. Results imply that a single measure is insufficient to assess occupational outcomes subsequent to a WRUEC. The importance of secondary prevention was highlighted. There is a need for focus on gradual-onset injuries, as well as those acute-onset injuries with risk for recurrence.

Overview Of Publicly Funded Managed Behavioral Health Care.

Using MEDLINE and other Internet sources, the authors perform a systematic review of published literature. A total of 109 articles and reports are identified and reviewed that address the development, implementation, outcomes, and trends related to Managed behavioral health care (MBHC). MBHC remains a work in progress. States have implemented their MBHC programs in a number of ways, making interstate comparisons challenging. While managed behavioral health care can lower costs and increase access, ongoing concerns about MBHC include potential incentives to under-treat those with more severe conditions due to the nature of risk-based contracting, the tendency to focus on acute care, difficulties assuring quality and outcomes consistently across regions, and a potential cost-shift to other public agencies or systems. Success factors for MBHC programs appear to include stakeholder involvement in program and policy development, effective contract development and management, and rate adequacy.

Assessing Health Care Reform: Potential Effects on Insurance Coverage Among Persons With Disabilities

The changes enacted by the Patient Protection and Affordable Care Act are designed to substantially increase health insurance coverage. The authors analyze the health care reforms to assess the potential for increased insurance coverage among persons with disabilities. They estimate that approximately 2 million persons with disabilities will be newly insured; however, they also find a probable unintended consequence of the health care reforms: that some persons with disabilities will lose their current Medicaid coverage. The article outlines policy changes that would prevent this unintended consequence before full implementation of the changes in 2014.

Mobility Limitations Negatively Impact Work Outcomes among Medicaid Enrollees with Disabilities

IntroductionFear of losing health insurance is believed to be a significant work barrier for people with disabilities in the US. We examined the relationship of different types of daily activity limitations to work outcomes among adults with a variety of disabling conditions for whom the risk of losing health insurance has been removed by enrolling in a Medicaid buy-in (MBI) program.Methods1093 working-age adults with disabilities in the Massachusetts MBI program responded to the MassHealth Employment and Disability Survey, which provided data on the types of disabling conditions and activity limitations members experienced as well as three work outcomes––work status of members; annual earnings above substantial gainful activity of working members; and plans to work in the future of non-working members.ResultsAmong different types of activity limitations, mobility limitations were generally associated with poorer work outcomes, regardless of disabling condition. Across members in three disability groups––psychiatric; physical; and co-occurring psychiatric and physical––those reporting mobility limitations were significantly less likely to be working or, if non-working, to be planning work than those reporting no or other types of limitations. There was an exception to this pattern with respect earnings among working members. Overall, work outcomes among members with co-occurring psychiatric and physical disabilities were most consistently negatively impacted by mobility limitations.ConclusionsRehabilitation providers aiming to promote entry into the workforce need to be aware of the varied ways in which mobility limitations may create barriers for people with all types of disabilities.

Screening for carpal tunnel syndrome in the workplace. An analysis of portable nerve conduction devices.

Several devices have been developed for rapid motor or sensory median nerve conduction testing. We evaluated the validity and reliability of the Neurosentinel (NS) and NervePace (NP) electroneurometer for sensory and motor testing, respectively, compared with formal electrodiagnostic studies (EDS), and examined their potential role in workplace screening for carpal tunnel syndrome (CTS). Thirty-two working subjects without CTS were examined and tested with the NS, NP, and EDS, and retested one week later. Subjects were selected who did not have CTS, other hand or nerve problems, or jobs with significant ergonomic risks, in order to decrease the likelihood of changes over time in median nerve function. Mean correlations of NP and NS with EDS latencies ranged from r = 0.069 to r = 0.85, with somewhat better correlation for NS (sensory) than NP (motor). Test-retest reliability was greatest for motor EDS (r = 0.86 to 0.91) and similar for sensory EDS, NS, and NP (r = 0.72 to 0.79); mean results were very similar. Based on the observed relationship between NS or NP and EDS results, confidence intervals were calculated to represent the range of EDS results consistent with a single NS or NP measurement. These intervals ranged from +/- 0.3 milliseconds (ms) for NS to +/- 0.6 msec for NP, with similar ranges for change over time in an individual. The magnitude of these intervals for a single test or individual implies that the NS and NP are unlikely to identify individuals with CTS or to detect changes over time that are not accompanied by symptoms or signs. The screening devices are not likely to be useful in confirming early CTS, when single latency values may be normal, and detailed EDS may be necessary to detect nerve entrapment. Compared with EDS, these devices have moderate validity and similar reliability; they are probably most useful for cross-sectional or longitudinal studies of groups, but care must be taken in using them for pre-placement or surveillance tests of individual workers. False-positive results may lead to discrimination, inappropriate referrals and interventions; false-negative tests can result in inappropriate reassurance and missed opportunities for intervention.