What is prevention and how can we use guidelines for the most important issues?

Transcription

1 What is prevention and how can we use guidelines for the most important issues? Carel Hulshof Jos Verbeek

2 Relation Work Health Work Health + income, contact, learning, self-worth, social functioning + helps recovery; platform interventions injuries, occupational and work-related diseases Health Work + vitality, inspiration, productivity sick leave, disability, costs Together sustained workability

3 What is prevention? (New model 2007) Description disease individual International Classification of Functions (ICF) Primary Prevention Healthy Healthy Universal prevention Population Secondary Prevention Risk factors or Selective prevention Symptoms Indicated Prevention Tertiary Prevention (care) (Chronically) ill Limitations in: Functions Activities Participation Care Care-related prevention Individual

4 Health Condition Function Activity Participation Personal factors External factors

5 Health Condition Function Activity Participation Personal factors External factors Clinical interventions

6 Health Condition Function Activity Participation Personal factors External factors Clinical interventions Behavorial interventions

7 Health Condition Function Activity Participation Personal factors External factors Clinical interventions Behavorial interventions Environmental interventions ICF model* and intervention options Adapted by PBA Smits and JHAM Verbeek, Coronel Institute of Occupational Health, AMC The Netherlands. EMUTOM project, August 2011 * ICF model, International Classification of Functioning, disability and health. ICF World Health Organization 2001

8 From an etiological to an intervention model Worker Health Behaviour Risk factor at work Disease, Disability, Injury Verbeek, Scand J WEH 2004

9 OSH Preventive Interventions Noise Reduction Education and Training Hepatitis B Vaccination Environmental interventions Behavioural Interventions Clinical Interventions Worker Health Behaviour Risk factor at work Disease, Disability, Injury Verbeek, Scand J WEH 2004

10 Questions that may arise from practice Consider your practice as one full of decisions about many aspects of occupational health and safety Questions that could arise: What could we do to prevent noise-induced hearing loss? Which treatment is the best for a worker with depression? What should I advise about healthy food in the canteen of this company? Evidence can then be used to inform our decision making together with our expertise and clients' values

11 Decisions in OH&S should be based on: Prof. Skills & Expertise Evidence-based practice Research Evidence (EBP) Client Preferences/ Values

12 How to find and apply best evidence? 1. Translate your problem into an answerable question 2. Search for the best evidence to answer it 3. Critically appraise its quality, impact and applicability 4. Apply to your specific case, population, or patient 5. Evaluate how well you are doing and how to improve

13 The evidence pyramid

14 Quality of OH care does not always meet professional standards Commercialization of OHS New occupational risks Growing informal economy (SME), coverage Shortage of physicians Scarcity of resources and training Influence of third parties (e.g. insurance companies) NL: Emphasis on sickness absence management or health promotion, neglecting preventive tasks

15 Why practice guidelines? To improve the quality of care support Evidence Based Practice keep up with fast scientific development decrease inter-professional variation Accountability ( transparency) Efficiency

16 What is an evidence-based guideline? A document with recommendations to support practitioners and care users, aimed at improvement of the quality of care,based on evidence, expertise and experiences of practitioners and care users (Working Group Guideline for Guidelines, Regieraad 2011)

17 Impossible d afficher l image. Impossible d afficher l image. MAETIS ARBO. WERKEN IS GEZOND Evidence-based guideline development Systematic reviews and meta-analyses quality assessment Q Randomised controlled trials Cohort, case control studies quality assessment quality assessment Conclusion including Level of evidence Considered judgement recommendation ( evidence plus experience ) Uncontrolled studies Expert opinion quality assessment - clinical relevance - patient safety - patient preferences - availability of services - organisation of care - impact on costs - legal / ethical consequences

18 Levels of evidence level support expression in guideline text A B C D 2 independent RCT's of high quality or 1 meta-analysis 2 independent RCT's of moderate quality or cohort/case-control studies uncontrolled studies or not enough support as in level 1 or 2 opinion of members project team 'there is evidence that...' 'one ought to...' 'it is plausible that...' 'one should...' there are indications that...' 'one may...' ' to the opinion of...'

19 NVAB-guidelines for occupational physicians Published: Low back pain Mental health disorders Visual acuity of VDU-workers Workers in sheltered workshops Upper limb disorders (RSI) Work-related asthma / COPD Contact dermatitis Noise-induced hearing loss Ischemic Heart disorders Pregnancy and Work Influenza Cancer and Work Diabetes and Work In preparation: Prevention of weight gain Latex allergy OSAS

20 Involvement NVAB in many multidisciplinary guidelines Carpal tunnel syndrome COPD Alcohol abuse Inflammatory bowel diseases Whiplash Obesity Cystic fibrosis Early interventions after disasters Obstructive sleep apnoea syndrome Atopic dermatitis Herniated lumbar disk Somatoform disorders Problematic use of drugs Multiple sclerosis Ankle injury Oncologic rehabilitation Urine incontinence Needle stick injuries Lyme s disease Low back pain Anxiety disorder Depressive disorder Chronic fatigue syndrome Cardiovascular risk management Heart failure Adjustment disorder/burnout Complex regional pain syndrome Chronic rhino sinusitis Sub fertility Rheumatic arthritis Domestic violence Treatment smoking addiction Complaints of arm, neck, shoulder Lower extremity amputation

21 UK guidelines in Occupational Health

22 Examples

23 Example bottleneck (from NHS Plus guideline on pregnancy) With the exception of hazards that are governed by specific legislation, there are no clear guidelines regarding the level of risk at which adjustments to work should be made for pregnant workers, or what adverse outcomes might result from poor risk control. There is evidence of inconsistency in the advice given to pregnant women, dependent upon who undertakes the risk assessment and how it is performed (Conrad et al. 2005)

24 Example recommendation

25 Conclusions An evidence-based guideline on prevention is an important tool in bridging the gap between research and practice Growing number of guidelines with information on work-related aspects available Implementation is frappez toujours : training, medical audit, feedback etc International collaboration may enhance quality and efficiency

26 Exercise Prevention of kidney disease: urine analysis

27 Urine analysis The medical pre-employment check ups in your occupational health services include a urine analysis of protein. Discuss with your neighbour if this leads to prevention of disease and if so if this is a cost-effective approach

28 Evidence The US Preventive Services Task Force concludes that the evidence is insufficient to assess the balance of benefits and harms for routine screening for CKD in asymptomatic adults.