High cost or frequent attender - both spend resources, but are they linked to work disability? A cohort study from occupational health primary care in Finland.

BACKGROUND: High use of services is associated with ill health and a number of health problems, but more information is needed on whether high use of services presents a risk for future pensions or disability. We aimed to investigate if defining patients as high cost (HC) or frequent attenders (FA) was more useful in occupational health services (OHS) as a predictor of future disability pension (DP). METHODS: This cohort study used medical record data from a large OHS provider and combined it with register data from the Finnish Centre for Pensions including disability pension decisions. A total of 31,960 patients were included and odds ratios for DP were calculated. Frequent attenders (FA10) were defined as the top decile of visitors according to attendance and high cost (HC10) as the top decile according to costs accrued from service use in 2015. Those patients that were not categorized as FA nor HC, but were eligible for the study were used as the control group (non-FAHC). The outcome measure (disability pensions) was analysed for years 2016-2017. RESULTS: FA and HC did not significantly differ in their risk for disability pension. Both groups' risk was higher than average users' risk (adjusted OR 3.47 for FA10, OR 2.49 for HC10 and OR 0.33 for controls). Both HC10 and FA10 received half of their disability pensions based on musculoskeletal disorders, while for non-FAHC only 28% of pensions were granted based on these disorders. The groups overlapped by 68%. CONCLUSIONS: High utilizers (both FA10 and HC10) have an increased likelihood of receiving a future disability pension. The chosen definition is less important than identifying these patients and directing them towards necessary rehabilitation.

Improved recording of work relatedness during patient consultations in occupational primary health care: a cluster randomized controlled trial using routine data.

BACKGROUND: Prolonging working careers is a key policy goal in ageing populations in Europe, but reaching this goal is complex. Occupational health services are in the best position to contribute towards prolonging working careers through preventing illnesses that cause work disability and early retirement. However, impacting on the trajectory between illness and work disability requires continuity of care and follow up, enabled through identifying patients at risk. We aimed to determine whether a combined educational and electronic reminder system in occupational health care could improve the recording and follow up of primary care visits made by patients at risk of work disability, and whether the system could impact on sickness absence rates. METHODS: This study is a pragmatic, cluster-randomized controlled trial using medical record data. Twenty-two Pihlajalinna Työterveys units were randomized into an intervention group receiving education and electronic reminders or a group receiving usual care through minimization methods. Patient consultation data were extracted from routine Pihlajalinna Työterveys patient registers from 2015 to 2017. In addition, process indicators were collected from the electronic system. Data were cleaned and analysed on an intention-to-treat basis using analysis of covariance. RESULTS: There was no significant difference between intervention and control units in terms of sickness absences of different duration. Process indicators suggested that there was a change in physicians' practice of recording patients' risk of work disability and work-relatedness of visits following the educational intervention. CONCLUSION: Education with an electronic reminder can change physicians' practice, but long-term follow up is needed to determine whether this impacts on patients' sickness absences. TRIAL REGISTRATION: ISRCTN Registry: ISRCTN45728263. Registered on 12 April 2016.

Frequent attenders at risk of disability pension: a longitudinal study combining routine and register data.

Aims: Frequent attendance in healthcare services is associated with ill-health and chronic illnesses. More information is needed about the phenomenon's connection with disability pensions (DPs). Methods: The study group comprised 59,676 patients divided into occasional- (1yFAs) and persistent frequent attenders (pFAs) and non-frequent attenders (non-FAs). Odds ratios for DP were analysed for these groups taking into account preceding sickness absence days. The awarded DPs were obtained from the Finnish Centre for Pensions and data on primary care visits were obtained from Pihlajalinna, a nationwide occupational healthcare provider. Results: 1yFAs and pFAs have more DPs than non-FAs. During follow-up, 14.9% of pFAs, 9.6% of 1yFAs and 1.6% of non-FAs had a DP decision of any kind. pFAs receive more partial and fixed-term decisions than the other groups and most permanent DPs are granted to 1yFAs. Musculoskeletal disorders are the most common reason for illness-based retirement in all groups but 1yFAs and pFAs have proportionally more mental disorders leading to DP. The group of non-FAs, on the other hand, has more DPs granted based on neoplasms. Both 1yFAs and pFAs have an increased risk of DP but the effect is diluted after taking into account preceding sick-leave. Conclusions: Frequent attendance of healthcare services, both occasional and persistent, is associated with increased risk of future DP. The association is linked to increased sickness absences. Frequent attenders should be identified and their rehabilitative needs evaluated. Frequency of consultation could be used in selecting candidates for early rehabilitation before sickness absences develop.

Trends in occupational diseases in Finland, 1975-2013: a register study.

OBJECTIVES: The objective was to investigate trends in the incidence of recognized and suspected cases of occupational diseases in Finland from 1975 to 2013, including variations by industry - and describe and recognize factors affecting variations in incidence. DESIGN: A register study. SETTING: The data consisted of recognized and suspected cases of occupational diseases recorded in the Finnish Registry of Occupational Diseases (FROD) in 1975-2013. PARTICIPANTS: Altogether 240 000 cases of suspected and recognized ODs were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES: From the annual workforce statistics and FROD data, we calculated the incidence of ODs and suspected ODs per 10 000 employees. For time trends by industrial sector, we used a 5-year moving average and a Poisson regression analysis. RESULTS: Annual average rates of ODs have varied from year to year. The total number was 25.0/10 000 employees in 1975 and 20.1/10 000 employees in 2013. Screening campaigns and legislative changes have caused temporary increases. When the financial sector was the reference (1.0), the highest incidence rates according to industrial sector were in mining and quarrying (9.87; 95% CI 8.65 to 11.30), construction (9.11; 95% CI 9.98 to 10.43), manufacturing (9.04; 95% CI 7.93 to 10.36) and agriculture (8.78; 95% CI 7.69 to 10.06). There is a distinct decreasing trend from 2005 onwards: the average annual change in incidence was, for example, -9.2% in agriculture, -10.3% in transportation and -4.7% in construction. The average annual decline was greatest in upper limb strain injuries (-11.1%). CONCLUSION: This study provides a useful overview of the status of ODs in Finland over several decades. These data are a valuable resource for determining which occupations are at an increased risk and where preventive actions should be targeted. It is important to study long-term trends in the statistics of ODs to see beyond the year-to-year fluctuations.

Occasional and persistent frequent attenders and sickness absences in occupational health primary care: a longitudinal study in Finland.

OBJECTIVES: Frequent attenders (FAs) create a substantial portion of primary care workload but little is known about FAs' sickness absences. The aim of the study is to investigate how occasional and persistent frequent attendance is associated with sickness absences among the working population in occupational health (OH) primary care. SETTING AND PARTICIPANTS: This is a longitudinal study using medical record data (2014-2016) from an OH care provider in Finland. In total, 59 676 patients were included and categorised into occasional and persistent FAs or non-FAs. Sick-leave episodes and their lengths were collected along with associated diagnostic codes. Logistic regression was used to analyse associations between FA status and sick leaves of different lengths (1-3, 4-14 and ≥15 days). RESULTS: Both occasional and persistent FA had more and longer duration of sick leave than non-FA through the study years. Persistent FAs had consistently high absence rates. Occasional FAs had elevated absence rates even 2 years after their frequent attendance period. Persistent FAs (OR=11 95% CI 7.54 to 16.06 in 2016) and occasional FAs (OR=2.95 95% CI 2.50 to 3.49 in 2016) were associated with long (≥15 days) sickness absence when compared with non-FAs. Both groups of FAs had an increased risk of long-term sick leaves indicating a risk of disability pension. CONCLUSION: Both occasional and persistent FAs should be identified in primary care units caring for working-age patients. As frequent attendance is associated with long sickness absences and possibly disability pensions, rehabilitation should be directed at this group to prevent work disability.

Frequent attenders in occupational health primary care: A cross-sectional study.

AIMS: This study characterizes frequent attenders in primary care provided by occupational health services (OHS) in Finland. METHODS: This is a nationwide cross-sectional study using medical record data from an OHS provider in 2015. Frequent attenders were defined as persons who were within the top decile of annual visits to healthcare professionals (frequent attender 10%, FA10) at any of the OHS's 37 stations. FA10s within this study consulted the OHS primary care unit eight or more times during 2015. We used logistic regression to analyse factors associated with frequent attendance in OHS primary care. The independent variables were age, gender, employer size and industry, health professionals visited and diagnoses given during visits to the OHS. The dependent variable was belonging to the FA10 group. RESULTS: Altogether 31,960 patients met the inclusion criteria and were included in the study. The FA10 group included 3617 patients, who conducted 36% of visits to healthcare professionals. The findings indicate that working within the manufacturing industry, health and social services, or public administration, and being employed in medium or large companies, are associated with frequent attendance. Frequent attendance was also associated with being female, diagnoses of the musculoskeletal system, or mental and behavioral disorders. In particular, depressive episodes and anxiety were associated with FA10s. CONCLUSIONS: This research characterized FA10 clients at a Finnish OHS. Illnesses of the musculoskeletal system and mental and behavioral disorders were accentuated among FA10s. The stability of the FA10 group, along with their sickness absences and work disabilities, should be investigated further.

Comparing occasional and persistent frequent attenders in occupational health primary care - a longitudinal study.

BACKGROUND: The aim of the study was to compare occasional and persistent frequent attenders in occupational health (OH) primary care and to identify the diagnoses associated with persisting frequent attendance. METHODS: This is a longitudinal study using electronic medical record data from 2014 to 2016 from an OH service provider. Frequent attenders were defined as patients in the top decile of annual visits to healthcare professionals (frequent attender 10%, FA10). FA10 were categorized to three groups according to the persistence of frequent attendance (1-year-FA, 2 year-FA, and persistent-FA = frequent attenders in all three years). This was used as the dependent variable. We used patient sex, age, employer size, industry and distribution of visits and diagnostic codes to characterize the different frequent attender groups. RESULTS: In total, 66,831 patients were included, of which 592 persistent frequent attenders (0.9% of the study population) consulted the OH unit on average 13 times a year. They made altogether 23,797 visits during the study years. The proportion of women and employees of medium and large employers increased among persistent-FAs when compared to the other groups. Multinomial logistic regression accentuated musculoskeletal disorders and to a lesser extent diseases of the respiratory and nervous system and mental disorders. One in five FA becomes a persistent-FA. CONCLUSIONS: Our results indicate that in the context of a working population the association of musculoskeletal disorders and persistent frequent attendance is emphasized. Persistent frequent attenders also create a substantial demand on physician resources. When planning interventions aimed at working age frequent attenders, subgroups suffering from musculoskeletal disorders should be identified as they are associated with persisting frequent attendance.

Impact of improved recording of work-relatedness in primary care visits at occupational health services on sickness absences: study protocol for a randomised controlled trial.

BACKGROUND: Employment protects and fosters health. Occupational health services, particularly in Finland, have a central role in protecting employee health and preventing work ability problems. However, primary care within occupational health services is currently underused in informing preventive activities. This study was designed to assess whether the recording of work ability problems and improvement of follow-up of work-related primary care visits can reduce sickness absences and work disability pensions after 1 year. METHODS/DESIGN: A pragmatic trial will be conducted using patient electronic registers and registers of the central pensions agency in Finland. Twenty-two occupational health centres will be randomised to intervention and control groups. Intervention units will receive training to improve recording of work ability illnesses in the primary care setting and improved follow-up procedures. The intervention impact will be assessed through examining rates of sickness absence across intervention and control clinics as well as before and after the intervention. DISCUSSION: The trial will develop knowledge of the intervention potential of primary care for preventing work disability pensions and sickness absence. The use of routine patient registers and pensions registers to assess the outcomes of a randomised controlled trial will bring forward trial methodology, particularly when using register-based data. If successful, the intervention will improve the quality of occupational health care primary care and contribute to reducing work disability. TRIAL REGISTRATION: ISRCTN Registry reference number ISRCTN45728263 . Registered on 18 April 2016.

Does an increased cesarean section rate improve neonatal outcome in term pregnancies?

PURPOSE: To clarify whether an increased cesarean section rate improves the short-term neonatal outcome in singleton term pregnancies with cephalic presentation. METHODS: A retrospective study of institutional data on the mode of delivery and neonatal outcome. The study included two cohorts: 1998-1999 (n = 7437) and 2004-2005 (n = 8505), since the institutional cesarean section rate increased sharply between these cohorts and has remained stable after the latter study period. RESULTS: The caesarean section rate almost doubled from 6.8 to 11.3 % (p < 0.001), during the study period. The rate of neonates suffering severe birth asphyxia remained low in both cohorts (0.4 vs. 0.6 %) and there were no significant differences in neonatal outcome (Apgar score <4 at 1 min and Apgar score <7 at 5 min, severe birth asphyxia, resuscitation or artificial ventilation) between the study periods. In the subgroup of neonates delivered vaginally, no significant differences were found in the above-mentioned neonatal outcomes between the cohorts. Apart from other outcomes admissions to neonatal intensive care unit increased significantly (p < 0.001) during the latter period (0.8 vs 1.6 %). CONCLUSIONS: Increasing cesarean section rate from a low to a moderate does not improve the short-term neonatal outcome in term singleton pregnancies. On the contrary neonatal intensive care unit admissions increased with increasing caesarean section rate. Furthermore it is possible to achieve good neonatal outcome with a low cesarean section rate.

Clinical and sonographic risk factors and complications of shoulder dystocia - a case-control study with parity and gestational age matched controls.

OBJECTIVES: To examine the clinical risk factors and complications of shoulder dystocia today and to evaluate ultrasound methods predicting it. STUDY DESIGN: Retrospective, matched case-control study at a University Hospital with 5000 annual deliveries. The study population consisted of 152 deliveries complicated by shoulder dystocia over a period of 8.5 years (January 2004-June 2012) and 152 controls matched for gestational age and parity. The data was collected from the medical records of mothers and children and analyzed by conditional logistic regression. Incidences and odds ratios were calculated for risk factors and complications. Antenatal ultrasound data was analyzed when available by conditional logistic regression to test for significant differences between study groups. RESULTS: Birthweight (OR 12.1 for ≥4000 g; 95% CI 4.18-35.0) and vacuum extraction (OR 3.98; 95% CI 1.25-12.7) remained the most significant clinical risk factors. Only a trend of an association of pregestational or gestational diabetes was noticed (OR 1.87; 95% CI 0.997-3.495, probability of type II error 51%). Of the complications of shoulder dystocia the incidence of brachial plexus palsies was high (40%). Antenatal ultrasound method based on the difference between abdominal and biparietal diameters had a significant difference between cases and controls. CONCLUSIONS: The impact of diabetes as a risk factor has diminished, which may reflect improved screening and treatment. Antenatal ultrasound methods are showing some promise, but the predictive value of ultrasound alone is probably low.