Occupational medicine specialist referral triggers: Mixed-methods analysis of teleconsult cases.

Background: Qualitative analyses can yield critical lessons for learning organizations in healthcare. Few studies have applied these techniques in the field of occupational and environmental medicine (OEM). Aims: To describe the characteristics of complex cases referred for OEM subspecialty evaluation and variation by referring provider's training. Methods: Using a mixed methods approach, we conducted a content analysis of clinical cases submitted to a national OEM teleconsult service. Consecutive cases entered between April 2014 and July 2015 were screened, coded and analysed. Results: 108 cases were available for analysis. Local Veterans Health Administration (VHA) non-specialist providers entered a primary medical diagnosis in 96% of cases at the time of intake. OEM speciality physicians coded significant medical conditions based on free text comments. Coder inter-rater reliability was 84%. The most frequent medical diagnosis types associated with tertiary OEM referral by non-specialists were endocrine (19%), cardiovascular (18%) and mental health (16%). Concern for usage of controlled and/or sedating medications was cited in 1% of cases. Compared to referring non-specialists, OEM physicians were more likely to attribute case complexity to musculoskeletal (OR: 2.3, 1.68-3.14) or neurological (OR: 1.69, 1.28-2.24) conditions. Medication usage (OR: 2.2, 1.49-2.26) was more likely to be a source of clinical concern among referring providers. Conclusions: The findings highlight the range of triggers for OEM physician subspecialty referral in clinical practice with employee patients. The results of this study can be used to inform development of provider education, standardized clinical practice pathways, and quality review activities for occupational medicine practitioners.

A study of the impact and efficacy of health fairs for farmers.

The purpose of this study was to evaluate the effectiveness of two regional multi-disciplinary farm health fairs, pairing cardiovascular and agricultural health and safety risk factor assessments and education, in agricultural regions in southern Minnesota in 1999 and 2001. This study explores the rationales and motives cited as having an influence on: (1) work practice and lifestyle adaptations, (2) resistance to such changes, and (3) compliance with health fair recommendations. Evaluation took the form of standardized telephone surveys and callbacks with an open-ended component administered by a parish nurse interviewer and conducted six months following each of the fairs. Participants had received individualized work practice and lifestyle recommendations based upon their medical results and questionnaire responses. Of the 378 total attendees at the two farm health fairs, 272 (72%) participated by filling out on-site questionnaires, and 284 (75%) completed a post-fair interview. Participants who were actively farming totaled 237 (63%) of all participants. A majority of those interviewed on callback (78%) reported either work safety or lifestyle changes, while 47% of those actively farming claimed varying work safety changes as a result of the fair. The conclusions drawn from the follow-up interviews include: (1) the two farm health fairs resulted in a substantial number of participants positively modifying lifestyle and work practices, (2) the stand-alone farm health fairs were effective in attracting farmers, and (3) low-level stressors identified in the participants could be effectively addressed by knowledgeable rural health care resources such as parish nursing.

Current health effects of agricultural work: respiratory disease, cancer, reproductive effects, musculoskeletal injuries, and pesticide-related illnesses.

Agriculture has experienced major bio-technological advances and economic and socio-cultural disruptions since the publication of "Agriculture at Risk" in 1988. At that time, it was recognized that there were acute needs in the prevention of musculoskeletal syndromes and injuries, agricultural respiratory disease, noise-induced hearing loss, pesticide-related illnesses, and concerns regarding the excesses of cancers noted in epidemiological studies of farmers. In this article, we discuss the progress made in identification of new respiratory syndromes related to confined animal feeding operations, pesticide-related illnesses, cancers implicating agricultural exposures, and ergonomics in agriculture. The focus is on the current state of knowledge in these areas, the author's recommendations for further improvement in research techniques, and the potential application of this information to improve human health in production agriculture nationwide.

Agricultural lung diseases.

Agriculture is considered one of the most hazardous occupations. Organic dusts and toxic gases constitute some of the most common and potentially disabling occupational and environmental hazards. The changing patterns of agriculture have paradoxically contributed to both improved working conditions and increased exposure to respiratory hazards. Animal confinement operations with increasing animal density, particularly swine confinement, have contributed significantly to increased intensity and duration of exposure to indoor air toxins. Ongoing research has implicated bacterial endotoxins, fungal spores, and the inherent toxicity of grain dusts as causes of upper and lower airway inflammation and as immunologic agents in both grain and animal production. Animal confinement gases, particularly ammonia and hydrogen sulfide, have been implicated as additional sources of respiratory irritants. It has become evident that a significant percentage of agricultural workers have clinical symptoms associated with long-term exposure to organic dusts and animal confinement gases. Respiratory diseases and syndromes, including hypersensitivity pneumonitis, organic dust toxic syndrome, chronic bronchitis, mucous membrane inflammation syndrome, and asthmalike syndrome, result from ongoing acute and chronic exposures. In this review we focus upon the emerging respiratory health issues in a changing agricultural economic and technologic environment. Environmental and occupational hazards and exposures will be emphasized rather than clinical diagnosis and treatment. Methods of prevention, from both engineering controls and personal respiratory perspectives, are also addressed.