Lawrence W. Raymond

A benefit-cost analysis of a worksite nurse practitioner program : First impressions

Objective:This study aimed to assess the initial impact of an on-site nurse practitioner (NP) initiative on the healthcare costs (HCC) among 4284 employees and their dependents. Methods:The authors analyzed HCC by two methods. First, they compared annualized actual values for the first 6 months of the startup year (2004) with those projected for 2004 on the basis of claims paid in 2002 and 2003. Both aggregate and per-individual HCC were used as the basis for comparison. The difference in HCC between projected and observed values for 2004 was defined as the benefit of the NP program. In a second analysis, HCC were calculated using 2003 paid claims for major diagnostic categories (MDC). These HCC were compared with those that would have been incurred had off-site care been used for the (annualized) number of such patients cared for by the NP in 2004 with the same MDC. The cost of the NP program was used as the denominator in calculating the benefit-to-cost ratio using the savings in HCC estimated by the two previously mentioned methods. Results:Annualized cost of the NP program was

Severe illness in furniture makers using a new glue: 1-bromopropane toxicity confounded by arsenic.

82,716. Savings in HCC using the first method were

Nurse practitioner services: three-year impact on health care costs.

1,313,756 per year, yielding a benefit-to-cost ratio of 15 to 1. Using the MDC analysis, the ratio was 2.4 to 1. This difference in ratios between the two estimates may partly be attributable to effects of other initiatives such as the wellness program and the Nurse Health Line. The latter was begun 10 weeks before the NP program, is available at all times, and is intended to minimize the need for workers and families to seek high-cost care at hospital emergency departments. Conclusions:The first 6 months of a new NP initiative yielded substantial reductions in HCC that warrant further analysis over longer periods of observation. However, the initial estimates may understate the aggregate value of the program because it may also reduce on-site injury and illness patterns and improve productivity, end points that were not assessed in this initial snapshot.

Medical surveillance of workers exposed to crystalline silica.

Objective: To describe the illnesses of four workers with high concentrations of serum bromide after exposure to glue containing 1-bromopropane (1-BP). Methods: We reviewed all available clinical records, examined the workers, and obtained additional urinary arsenic values. We used standard autoanalyzer and other routine methods for blood and urinalysis. Results: All four workers had symptoms and abnormal physical findings when hospitalized, remaining symptomatic with abnormal examinations 3 months later. Milder symptoms persisted in two workers, 8 years after their initial illnesses. Both have returned to work. Follow-up was unavailable for the other two workers. Conclusions: Severe illness occurred in four gluers after 1-BP exposures associated with elevated levels of serum bromide. All had elevated urinary arsenic concentrations, the source of which remains unknown, but which confound interpretation of the abnormal bromide levels and clinical findings present during the acute illnesses.

Protecting health care workers from tuberculosis

Objective: In 2005, our initial analysis of the impact on health care costs (HCC) of providing on-site Nurse Practitioner (NP) services showed favorable results. Methods: We measured the effects of the NP program on HCC in two ways. Method 1 compared actual HCC for 2005 to 2007 versus projected HCC, the latter based on medical payments in 2002 to 2004, before the NP intervention. Method 2 was a microanalytic comparison of the HCC of nine Major Diagnostic Categories responsible for 88.5% of all conditions treated by the NP from July 2005 to December 2006. Results: Annualized cost of the NP program was

Stress testing in the medical evaluation for hazardous materials duty: Results and consequences in three groups of candidates

124,750. Savings in HCC using the first method were

Obesity and treadmill exercise duration in Hazmat candidates.

1,089,466 per year, yielding a benefit-to-cost ratio of 8.7 to 1. Savings in HCC using the second method reflected a ratio of 2.0 to 1. In addition, method 1 reflects HCC savings which may be due to the addition of a 24/7 Nurse Help Line. Conclusions: This 3-year analysis confirms our preliminary findings that an on-site NP has a favorable benefit-to-cost function. Longer-term analyses are needed to confirm these findings.

A Thermal Stress Treadmill Walk for Clinic Evaluation of Candidates for Hazardous Materials (HazMat) Duty

Silica is a major component of sand, rock, and mineral ores and is the second most common mineral in the earth’s crust, next to feldspar. The generic term refers to the chemical compound silicon dioxide (SiO2), which occurs naturally in crystalline, amorphous, and glassy states. It is crystalline silica that poses the occupational respiratory hazard. Structurally, crystalline silica is composed of a three-dimensional network of silicon/oxygen tetrahedrons (SiO4) crosslinked at each of the four corners. Variations in the molecular arrangement of the silicon tetrahedron result in different polymorphs of silica. The three major industrial types of crystalline silica include quartz, cristobalite, and tridymite, with other types being less important. Crystalline silica is essentially insoluble in water, but its solubility is increased with heating or increasing pH. It also reacts with most metallic oxides. Amorphous, noncrystalline, or glassy varieties of silica result from the completely random orientation of the silicon dioxide structural units, occurring in nature as diatomaceous earth, vitreous silica, or volcanic glass. These are classified as nuisance dusts whose exposures are relatively harmless. However, amorphous silica can transform into crystalline structures (eg, cristobalite) when exposed to high temperatures and pressures. More than one million workers in the United States are exposed to crystalline silica, with more than 100,000 of these workers involved in activities associated with a high risk for silica exposure. These high-risk activities include mining, rock drilling, construction activities, steel rolling and finishing mills, foundry work, and abrasive blasting with silica-containing material. The current Occupational Safety and Health Administration (OSHA) permissible exposure limit (PEL) for respirable crystalline silica is a respirable dust concentration of 10 mg/m divided by (% SiO2 2) averaged over an 8-hour shift. For example, dust composed of 98% crystalline silica has a PEL of 10/(98 2) 0.1 mg/m. However, convincing data indicate that the current OSHA PEL does not provide sufficient protection from the development of silicosis. Moreover, OSHA found that 48% of industry sites inspected during 1980 to 1992 had exposures to respirable silica in excess of the PEL. Despite some optimistic views on the decline of silicosis, its persistence is a matter of record, and some students of the disease believe its incidence is on the increase. OSHA has found that overexposure to silica remains widespread; the U.S. estimated death rate from silicosis in recent years is up to 300 per year. The purpose of this American College of Occupational and Environmental Medicine (ACOEM) position statement is to recommend objectives, key elements, and implementation strategies for a medical surveillance program for workers exposed to silica. The program would blend with recent increased efforts to prevent and eventually eliminate silicosis at both the national and international levels. Overview of Health Effects of Silica

Reassessment of an Asthma Diagnosis

The resurgence in cases of active pulmonary tuberculosis (TB) and the emergence of drug-resistant strains of TB have increased the risk that health care workers (HCWs) may acquire serious TB infections which may not respond to usual therapy. Multiple steps are needed to reduce this risk. These include updated periodic training of HCWs to maintain awareness of potential risks of TB; optimizing the design, ventilation, and patient flow in clinical spaces; periodic TB surveillance testing of HCWs; appropriate use of effective respiratory protection; active infection control procedures; and periodic updating of written TB control plans.

Heat Stress Testing for Hazmat Duty: Results of Pilot Study of a New Protocol

Objective: The objective of this study was to determine the yield of exercise stress testing (GXT) and other methods for evaluating candidates for HAZMAT duty. Methods: The authors conducted an analysis of prior and current records of GXTs, medical examinations, blood tests, chest radiographs, spirometry, and audiometry in 190 candidates. The authors also conducted scrutiny of GXT results, using Duke Treadmill Score (DTS), Chronotropic Index (CI), and Heart Rate Recovery (HRR). Results: Seven candidates were disapproved by history and/or physical examination. Twenty-one others were deferred for GXT-induced, marked hypertension, and/or ST depression ≥2 mm. The latter appeared to be false-positive indications of ischemia, low risks confirmed by DTS, CI, and HRR. Heat stress was not induced in 26 subjects so evaluated. Conclusions: GXT identified marked hypertension in 12 HAZMAT candidates and ischemic ST changes in 10, the latter appearing to be false-positives. Other testing yielded useful baselines, rarely disqualifying.