Western Occupational & Environmental Medical Association
Leading Occupational & Environmental Medicine

e-Newsletter – August 2010

Welcome to WOEMA’s new e-newsletter. After over 50 years, gone is WOEMA’s printed newsletter for this new electronic format. WOEMA is committed to providing on-going communications to members while reducing its carbon footprint by eliminating paper usage. WOEMA members receive the full version of the newsletter via email every other month and may also access contents on this website. It includes links to pertinent information. — Peter Swann, MD, FAAFP, Newsletter Editor

In this issue…
• President’s Message
• WOEMA’s Voice Heard at FedOSHA Conference
• Get Ready for the Western Occupational Health Conference!
• WOHC 2010 offers a new opportunity to connect with culturally diverse colleagues.
• News You Can Use from the Literature
Orford Receives Award and Becomes President-elect of ArMA

President’s Message by Paul Papanek MD MPH FACOEM

We Occupational Medicine physicians know that Workers’ Compensation (WC) procedures add an extra burden to our clinical tasks, and we also know that WC fee schedules in many states, particularly California, do not compensate us very well for carrying this extra burden.
  In particular, the work of primary care Occupational Medicine is reimbursed poorly under California Workers’ Compensation, as compared with other states or Federal Workers’ Compensation, or even Medicare.  Moreover, the California Official Medical Fee Schedule (OMFS) has not kept pace with general inflation over the past two decades, despite a 2004 legal mandate that the California Division of Workers’ Compensation (DWC) must revise the fee schedule periodically.

Through the activities of our Legislative Affairs Committee, WOEMA continues to advocate for fairer fee schedules for primary care Occupational Medicine.  This summer, we collaborated with several other medical societies in submitting comments about proposed changes to the California fee schedule.  While we were pleased that DWC requested modest increases in fees for Evaluation and Management (E&M) codes – increases that would average about 15% to 30% for the commonest codes-we were disappointed that the proposed regulations fell far short of what Occupational Medicine practitioners need and deserve.

As with all fee schedule discussions, the devil was in the details. Through these newly proposed regulations, DWC would finally implement a change to a resource-based relative value scale (RBRVS), incorporating into the fee schedule a primary care Conversion Factor of 42.  This number may initially sound modestly attractive, but sadly leaves a gap when compared against Conversion Factors for surgery (45), or against the current Conversion Factor for federal workers’ compensation (about 53), while failing to add any factor extra for geographic factors as other RBRVS rules typically do.  Furthermore, these proposed regulations would change the coding “ground rules” to those used by Medicare (the CMS ground rules), which are famously ill-suited to the kinds of musculo-skeletal problems suffered by injured workers.  Adoption of the CMS ground rules is likely to result in a level of downcoding which would wipe out any increases due to the Conversion Factor changes.  By now, you are probably aware of WOEMA’s comments to DWC about these concerns, which are posted in detail on our website under Legislative / Regulatory Agenda and Updates.

The WOEMA Legislative Committee has recently proposed that DWC should undertake a study of how different approaches to coding and ground rules would affect medical quality under Workers’ Compensation, since we recognize that there is very little reliable data about how best to link fees to quality outcomes, especially for low acuity soft tissue injuries to the spine or extremities.  It’s time to resolve some of these coding controversies with solid data, and we anticipate that both DWC and WC payers should be receptive to such an approach.

WOEMA will continue to push for fairer fee schedules in all of our member States, and we continue to encourage WOEMA members to add their own voices and testimony about their personal experiences in the regulator process, such as that recently held by the California DWC.

I also wanted to take a little space in this newsletter to highlight an important policy discussion for both ACOEM and WOEMA, about advocating for new regulations from OSHA or other government agencies.  I have personally observed that our leaders within both ACOEM and WOEMA are attuned and very sensitive to the breadth of political views within our College, and recognize that the issue of government regulation of business is a topic that can sometimes trigger controversy.   Accordingly, recognizing that there are always competing interests when government regulates business, under what circumstances should WOEMA or ACOEM advocate for additional or more stringent occupational or environmental regulation of American businesses?

I think we should step up particularly in those cases when we see a convergence of three critical factors – a likelihood of improved worker health and safety, scientific evidence of regulatory efficacy, and improved professional well being for our own members.

To that end, WOEMA has taken strong advocacy positions on a number of regulatory issues in the past two years, and I’ll cite two areas where it appears that new and stronger regulations are reasonably likely to be effective both in improving the health of workers and in benefiting the Occupational Medicine practices of our members: namely, occupational lead poisoning and hazard communication.

With regard to occupational lead poisoning, it is disheartening that more than 30 years after the promulgation of the initial OSHA Lead Standard for general industry, OSHA continues to sanction blood lead levels that are known to be unsafe.  It is also disheartening to note that the OSHA Standards give Occupational Medicine physicians a relatively minor role in controlling occupational lead poisoning.   Improved OSHA standards, whether at the state or federal level, should, we believe, take account of the scientific advances of the past 30 years with regard to lead toxicity, and should also take advantage of the special expertise of Occupational Medicine physicians in eradicating a disease that should long ago have gone extinct.

With regard to Hazard Communication for American workers, neither federal nor state OSHA programs have taken advantage of more than two decades of experience, to mandate best practices – which WOEMA and ACOEM believe should probably include improved requirements for written wellness and prevention plans, again taking advantage of the special skills of Occupational Medicine physicians, and the proven benefits of workplace wellness programs.

WOEMA continues to advocate at the state and federal level for updated rules about Injury and Illness Prevention Programs – an innovation that would benefit our members, while boosting the health and safety of the American workforce.

These are the kinds of opportunities we must seize. Thank you for your ongoing support of WOEMA.  Please continue to let us know how we can serve you better.  Don’t forget to sign up for WOHC.  See you in Newport Beach!

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WOEMA’s Voice Heard at FedOSHA Conference

Federal OSHA is poised to enact new regulations on preventive planning for workplace health and safety that may be among the most significant steps OSHA has ever taken to protect American workers, as it considers a new Standard on Hazard Communication that would be modeled after California’s requirement for Injury and Illness Prevention Plans (IIPP’s).  On Tuesday, August 4, 2010, Dr. Paul Papanek represented WOEMA at a stakeholder meeting held by Federal OSHA in Sacramento, aimed at gathering information about how best to craft such a Standard.  WOEMA and ACOEM have championed such a step by Federal OSHA, arguing that a national requirement for Injury and Illness Prevention Programs would raise the bar on worker safety, and level the national playing field, since over 20 states in addition to California already require some version of IIPP’s.

Among the nearly 40 stakeholders at the meeting, most of whom spoke strongly about the likely benefits of such a new regulation, WOEMA argued for more involvement by Occupational Medicine physicians in preparing IIPP’s, particularly in workplaces where medical surveillance is required.  WOEMA also urged Federal OSHA to explore mechanisms to incorporate health and wellness planning into IIPP’s, particularly since we know that reducing health risk factors correlates with decreased reported injury rates.

OSHA announced that it will probably require another 18 months before the promulgation of a final rule, and OSHA is expected to publish the proceedings of this  and other stakeholder meetings on its website in the fall.

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Get Ready for the Western Occupational Health Conference!

Fast approaching is the annual Western Occupational Health Conference, scheduled for September 30 to October 2, in beautiful Newport Beach, California.  Conference highlights will include a clinical workshop based on the new ACOEM Guidelines for hand injuries, hands-on training on office ultrasound and wound closure, a timely presentation on the impact of Health Care Reform on Occupational Medicine practice by Herb Schultz, new regional director of the US Dept of HHS, a keynote address by NIOSH Director Dr. John Howard, a talk about DOT exams by Dr. Natalie Hartenbaum (this year’s ACOEM President), combined with our usual five-star WOEMA hospitality, opportunities for tennis and golf, side trips to Disneyland and other local points of interest, interesting occupational site visits, and much more.  Two brief related news flashes: 1) the latest edition of Dr. Natalie Hartenbaum’s must-have text on DOT exams (5th edition) has just hit bookstores;  2) another excellent conference on Occupational Medicine, the annual Southern California Kaiser Permanente Occupational Medicine Symposium, is scheduled for Saturday August 14, and is open to all. 

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WOHC 2010 offers a new and different opportunity to connect with culturally diverse colleagues. A Saturday morning “Special Interests” breakfast meeting is offered for attendees who speak languages other than English. Come to share your cultural experiences, offer suggestions for treating patients, and meet others with similar as well as divergent ideas.

WOHC 2010 提供了一個新的和不同的機會與不同文化的同事。星期六早上的”特殊利益”的早餐會,旨在參加者誰講英語以外的語言。來分享您的文化經驗,為治療病人提供建議,並滿足其他有類似和不同的想法。

WOHC 2010 ofrece una oportunidad nueva y diferente para conectarse con colegas de diversas culturas. El sábado por la mañana “intereses especiales” desayuno de trabajo busca asistentes que hablan otros idiomas aparte del Inglés. Ven a compartir sus experiencias culturales, ofrecer sugerencias para el tratamiento de los pacientes y conocer a otros similares, así como las ideas divergentes.

WOHC 2010 يوفر فرصة جديدة ومختلفة للتواصل مع الزملاء المتنوعة ثقافيا.
في صباح اليوم السبت “المصالح الخاصة اجتماع على الافطار” تسعى الحضور الذين يتكلمون لغات أخرى غير اللغة الإنجليزية. تأتي لتبادل الخبرات الثقافية الخاص ، تقديم اقتراحات لعلاج المرضى ، ومواجهة أخرى مع مماثلة ، وكذلك الأفكار المتباينة.

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News You Can Use from the Literature
by Constantine J. Gean, MD, MS, MBA, FACOEM

A useful review of the latest journal articles of interest to the field of occupational medicine.

Adverse childhood experiences (ACEs) may be associated with a 3-fold increased risk of lung cancer (RR = 3.18-3.55), particularly premature death from lung cancer per a prospective cohort study of 17,337 adults during 1995-1997.  ACE score (= count of the 8 categories of ACEs – abuse (emotional, physical, sexual), witnessing domestic violence, parental separation or divorce, or growing up in a household where members had mental illness, substance abusers, or were sent to prison). Incident lung cancer (through 2005 follow-up) was ID’d via (1) hospital discharge records and (2) mortality records obtained from the National Death Index. Authors note the increase in risk may only be partly explained by smoking, suggesting other possible mechanisms. BMC Public Health. 2010 Jan 19;10:20

An increased risk of spontaneous abortion was associated with the use of antidepressants (OR = 1.68) [(SSRI alone (OR=1.61), SNRI alone (OR=2.11) and combined use of antidepressants from different classes (OR=3.51)] per a nested case-control study of 5,124 women in the Quebec Pregnancy Registry with clinically detected spontaneous abortion (10 randomly selected matched controls were obtained from the registry for each case). Paroxetine, venlafaxine or the combined use of different classes of antidepressants were especially problematic. CMAJ. 2010 May 31. [Epub ahead of print]

Pilots will now be able to fly on select Antidepressants as of 4/5/10. The FAA will now issue special certificates to pilots with mild to moderate depression who take one of four antidepressant medications-Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), or Escitalopram (Lexapro). These pilots will be allowed to fly if satisfactorily treated on the medication for at least 12 months. Per FAA a medical bulletin (DOT/FAA/AM-06/5 ), between 1993 and 2002, there were 16 “aircraft-assisted suicides”. FAA.gov

62%  of lumbar disc herniation (LDH) did not have a specific patient-identified event associated with onset of symptoms, and a history of an inciting event was not associated with more severe clinical presentation, per a study of 154 adults with lumbosacral radicular pain and LDH confirmed by MRI. This cohort study with prospective recruitment and retrospective data collection on inciting events used Oswestry Disability Index, the visual analog scale (VAS) for leg pain, and the VAS for back pain as outcome measures. Patient-identified inciting event were most commonly associated with nonlifting activities (comprising 26% of all LDH). Heavy lifting (6.5%), light lifting (2%), nonexertional occurrences (2%), and physical trauma (1.3%) accounted for relatively small proportions of all LDH. The Spine Journal 10 (2010) 388-395

The 16 mg Ruyan V8 electronic nicotine delivery device (“e cigarette”, “ENDD”) alleviated desire (rr=0.82 ) to smoke after overnight abstinence, was well tolerated and had a pharmacokinetic profile more like the Nicorette inhalator than a tobacco cigarette in a single-blind, randomized, repeated measures cross-over trial of 40 adult dependent smokers of 10 or more cigarettes per day. Participants were randomized to use ENDDs containing 16 mg nicotine or 0 mg capsules, Nicorette nicotine inhaler or their usual cigarette on each of four study days 3 days apart, with overnight smoking abstinence before use of each product. Tob Control. 2010 Apr;19(2):98-103.

FDA Smokeless Tobacco Products – Evaluation of e-cigarettes – an FDA study found trace amounts of some of the potentially toxic chemicals found in tobacco in some electronic cigarette nicotine cartridges. [read more]

The odds of having Metabolic Syndrome (MetS) were 10% lower for each additional 1,000 accelerometer (pedometer)-determined steps/day (OR=0.90), per a study of 1,446 adults (48.2% men, 33.5% with MetS, mean BMI=28.7) in ‘05-‘06 NHANES. Likelihood of having MetS was OR=0.28 for active to highly active, and OR=0.60 for low to somewhat-active, when compared to sedentary adults.AJPM2010 Jun;38(6):575-82

The U.S. FDA approved the Amgen drug denosumab (Prolia), an injectable treatment for postmenopausal women with osteoporosis who are at high risk for fractures. Prolia is injected once every six months as opposed to existing drugs. Safety and efficacy was shown in a three-year, randomized, double-blind, placebo-controlled trial of 7,808 postmenopausal women ages 60 to 91 years. Prolia reduced the incidence of vertebral (rr=0.32), non-vertebral (rr=0.80), and hip fractures (rr= 0.60) in postmenopausal women with osteoporosis. [read more]

Increasing backpack loads significantly compressed lumbar disc heights measured by MRI scans  in children) while standing (3 boys and 5 girls, age 11 ± 2 years) with 4, 8, and 12 kg backpack loads (~10%, 20%, and 30% of body weights). Endpoints were back pain, disc compression and lumbar asymmetry (coronal Cobb angle between S1 and L1 superior endplates) and 4 of the 8 subjects had Cobb angles > 10° during 8-kg backpack loads. Spine. 2010;35(1):83-88

“Practice Guidelines for Chronic Pain Management: An Updated Report” was issued in April, 2010 by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010; 112(4):810 -33

The American Heart Association (AHA) will place its logo on boxes for the Nintendo Wii FitTM Plus and Wii Sports ResortTM software and for the WiiTM Game system that plays this software beginning this summer. The AHA and Nintendo will also jointly launch an online information center endorsing the benefits of physically active play and active lifestyles – this is to address the fact that 70% of Americans do not meet the levels of physical activity recommended in AHA guidelines. [read more] [read more]

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Orford Receives Award and Becomes President-elect of ArMA

Robert Orford, MD,
 a past president of WOEMA and ACOEM was recently honored with a leadership award from the Arizona Medical Association (ArMA) and was also elected President-elect of ArMA. Upon accepting the award, Orford said “I am hoping to take some of the skills I have learned as an occupational physician, and as a national leader of a medical specialty, and apply them to my role as a senior leader in ArMA.”  We have no doubt he will do just that — congratulations and kudos to Bob from all his WOEMA colleagues!