View
216
Download
1
Tags:
Embed Size (px)
Citation preview
Diabesity:Diabesity:How Diabetes and Obesity How Diabetes and Obesity
Are Changing Workers’ Comp Are Changing Workers’ Comp
SCWCEA 2009SCWCEA 2009
Brian J. Caveney, MD, JD, MPHBrian J. Caveney, MD, JD, MPH
Duke Occupational & Environmental MedicineDuke Occupational & Environmental Medicine
ObjectivesObjectives
epidemiology of obesity & diabetes epidemiology of obesity & diabetes
economic and legal impact on employerseconomic and legal impact on employers
risk of work injuryrisk of work injury
difficulties in causation analysisdifficulties in causation analysis
challenges in addressing obesity & challenges in addressing obesity & diabetes lifestyle factors & RTWdiabetes lifestyle factors & RTW
Obesity in Adults - 2007Obesity in Adults - 2007
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
© CDC, BRFSS, 2007© CDC, BRFSS, 2007
Obesity Prevalence in The U.S.Obesity Prevalence in The U.S.
46%
56%
65% 66%
75%
14%
23%31%
34%41%
15% 15%
0%
10%
20%
30%
40%
50%
60%
70%
80%
1976 - 1980 1988 - 1994 1999 - 2000 current 2015 Est.
overweight (BMI >25) obese (BMI > 30) HP 2010 Goal
Sources: Flegal et al. JAMA 2002; Wang et al, Epidemiologic Reviews 2007
0
1
2
3
4
5
6
7
1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06
Year
Per
cen
t w
ith
Dia
bet
es
0
2
4
6
8
10
12
14
16
18
20
Nu
mer
wit
h D
iab
etes
(M
illi
on
s)Percent with Diabetes
Number with Diabetes
Number and Percentage of U.S. Population with Diagnosed Diabetes
Source: CDC at http://www.cdc.gov/diabetes/statistics
Life ExpectancyLife Expectancy
““the steady rise in life expectancy during the the steady rise in life expectancy during the past two centuries may soon come to an end.”past two centuries may soon come to an end.”
► Olshansky et al., NEJM, 352(11): 1138-1145 (2005)Olshansky et al., NEJM, 352(11): 1138-1145 (2005)
Just 30 # overweightJust 30 # overweight 1 - 6 YLL1 - 6 YLL20 yo WM 100 #20 yo WM 100 # up to 13 YLL up to 13 YLL20 yo BM BMI > 4520 yo BM BMI > 45 11 - 20 YLL11 - 20 YLL
► Fontaine et alFontaine et al., JAMA., JAMA 289: 187-193 (2003) 289: 187-193 (2003)
►Morbidity: obesity = 20 years of aging!Morbidity: obesity = 20 years of aging!
Health Risks Associated with ObesityHealth Risks Associated with Obesity
Premature deathPremature deathType 2 diabetesType 2 diabetesHeart diseaseHeart diseaseHigh blood cholesterolHigh blood cholesterolStrokeStrokeHypertensionHypertensionGallbladder diseaseGallbladder diseaseOsteoarthritis Osteoarthritis (degeneration of cartilage (degeneration of cartilage and bone in joints)and bone in joints)Sleep apneaSleep apneaAsthmaAsthmaBreathing problemsBreathing problemsIncreased surgical riskIncreased surgical risk
Cancer (endometrial, colon, Cancer (endometrial, colon, kidney, gallbladder, and kidney, gallbladder, and post-menopausal breast post-menopausal breast cancer)cancer)Complications of pregnancyComplications of pregnancyMenstrual irregularitiesMenstrual irregularitiesHirsutism (presence of Hirsutism (presence of excess body and facial hair)excess body and facial hair)Stress incontinence (urine Stress incontinence (urine leakage caused by weak leakage caused by weak pelvic-floor muscles)pelvic-floor muscles)Psychological disorders Psychological disorders such as depressionsuch as depressionPsychological difficulties Psychological difficulties due to social stigmatizationdue to social stigmatization
Obesity is Associated with an Increased Risk of:
(Adapted from http://win.niddk.nih.gov/statistics/index.htm)
How Much Does Obesity Cost?How Much Does Obesity Cost?
Estimated $200 billion / year U.S. aloneEstimated $200 billion / year U.S. alone
Over Over 10%10% of all health care costs (20% by 2020) of all health care costs (20% by 2020)
Up to 60% of the cost of diabetesUp to 60% of the cost of diabetes
27% of health insurance increase (1987 – 200127% of health insurance increase (1987 – 2001))Average taxpayer = $175 (Med/Med)Average taxpayer = $175 (Med/Med)
CDC CDC << 400,000 deaths per year in U.S. 400,000 deaths per year in U.S.
Add. 350M gallons jet fuel last 10 yearsAdd. 350M gallons jet fuel last 10 years
Revert to 1998 - $254B to GDPRevert to 1998 - $254B to GDP
% increase in health costs% increase in health costs
Age
Smoking Obesity
%
Source: PLoS Med 5(2):242 (2008)
Other Costs in the WorkplaceOther Costs in the Workplace
2 - 3 X the sick days & other measures of 2 - 3 X the sick days & other measures of absenteeismabsenteeism
Up to 3 X likelihood of disabilityUp to 3 X likelihood of disability
Decreased productivity (presenteeism)Decreased productivity (presenteeism)
Increased group life & disability premiumsIncreased group life & disability premiums
Decreased morale & cooperationDecreased morale & cooperation
Major Workers’ Compensation implicationsMajor Workers’ Compensation implications
Source: Schmier et al, Scand J Work Env Health 2006
Costs of DiabetesCosts of Diabetes
$174 – 200 Billion/year$174 – 200 Billion/year
1 of every 5 health care dollars spent on 1 of every 5 health care dollars spent on diabeticsdiabetics
2.3 X cost of non-diabetics 2.3 X cost of non-diabetics ($ 6649/yr($ 6649/yr))
1 million more Dxs per year1 million more Dxs per year
1/3 will develop in lifetime1/3 will develop in lifetime
Productivity loss of 6.6% (14 days/year)Productivity loss of 6.6% (14 days/year)Source: American Diabetes Association Stmt (2008)Source: American Diabetes Association Stmt (2008)
HealthFactors
Anxiety/Stress
Job
Factors!
Economy/Financial/Home/Life/Personal
Sleep, physical, mental
Other workplace impactsOther workplace impacts
Sleep apnea – recovery, CDLs shiftwork Sleep apnea – recovery, CDLs shiftwork
Arthritis – each 2# gain, 9-13% riskArthritis – each 2# gain, 9-13% risk
Diabetes – recovery time, wound healing, Diabetes – recovery time, wound healing, CDLs and shift workCDLs and shift work
Heat intolerance – WC casesHeat intolerance – WC cases
Response to neurotoxins/pesticidesResponse to neurotoxins/pesticides
Carpal tunnel syndrome - causationCarpal tunnel syndrome - causationfrom Schulte et al., AJPH 2007
Odds of Incurring an Acute Sprain or Strain
11.49
2.22
3.79
00.5
11.5
22.5
33.5
4
BMI < 25 BMI 25 - 30 BMI 30 - 40 BMI > 40
odds ratio
Source: Pollack et al. A J Epi 166(2) 2007
Hopkins Analysis of AlcoaHopkins Analysis of Alcoa
Ostbye, T. et al. Arch Intern Med 2007;167:766-773
Mean Indemnity Claims Costs, Medical Claims Costs, and Number of Lost
Workdays per Claim by Body Mass Index (BMI) Category
11x
7x
13x
Normal BMI
Increased Cost by Length of Claim, Obese vs. Non-Obese Claimant
12.8
4.55.3
0123456
0 12 36 60months
clai
m c
ost
mu
ltip
le
Source: adapted from Laws C and Schmid F. Reserving in the Age of Obesity. © Copyright 2009 National Council on Compensation Insurance, Inc.
Sprague v. SAIFSprague v. SAIF
Sprague injures knee in 1976, again 1999Sprague injures knee in 1976, again 1999
Gained > 100 # in interim, devel. arthritisGained > 100 # in interim, devel. arthritis
Surgeons would not operate b/c wt.Surgeons would not operate b/c wt.
Had gastric bypass to reduce weight to Had gastric bypass to reduce weight to undergo knee surgeryundergo knee surgery
Couldn’t argue inj. caused obesity, but that Couldn’t argue inj. caused obesity, but that tx for obesity necessary to tx injurytx for obesity necessary to tx injury
Indiana, NC, etc…Indiana, NC, etc…
Oregon W.C. Board A133701
5 Models of the Interrelationships of Work, Obesity, and Disease
•Causation
•Exacerbation
•Apportionment
© Schulte et al., AJPH 2007
Diabetic complicationsDiabetic complications
Increased likelihood of many conditionsIncreased likelihood of many conditions
Harder treatment – medication tolerability, Harder treatment – medication tolerability, procedure risk, wound healingprocedure risk, wound healing
ADA Statement on EmploymentADA Statement on Employment ““Diabetes usually has no effect on an individual’s Diabetes usually has no effect on an individual’s
ability to do a particular job.”ability to do a particular job.” Capacity to judge safety difficultCapacity to judge safety difficult Hypo- vs. hyperglycemiaHypo- vs. hyperglycemia ““certain types of work schedules…can make it difficult certain types of work schedules…can make it difficult
…to manage diabetes effectively.”…to manage diabetes effectively.”
Diabetic adult self-report: at least 1 Diabetic adult self-report: at least 1 day in last 30 (2004)day in last 30 (2004)
Source: CDC
Employer ResponseEmployer Response
IndividualIndividual Assume healthy and able to do jobAssume healthy and able to do job Robust ADA review processRobust ADA review process Get the right people for the jobGet the right people for the job
Job Level reviewJob Level review Know physical limits of each jobKnow physical limits of each job
Workplace Environment & BenefitsWorkplace Environment & Benefits
Carriers
Engineering/Operations
Facilities
HR/ Benefits
Legal
HealthPlan
Cafeteria
Management
Occ. Health
SAFETY
RISKMANAGE-
MENT
Duke Transition to FitnessDuke Transition to Fitness
WC claims with delayed recovery WC claims with delayed recovery
Transition “patient” to “wellness” Transition “patient” to “wellness”
⅓⅓ back, ¼ shoulder, others – most obeseback, ¼ shoulder, others – most obese
Free 3 months @ Duke Fitness Clubs with Free 3 months @ Duke Fitness Clubs with supervision, then on ownsupervision, then on own
94% satisfaction, over 88% (2007) said 94% satisfaction, over 88% (2007) said likely to make long-term lifestyle changelikely to make long-term lifestyle change
Return to Work PlanReturn to Work Plan
Perhaps extra scrutiny for RTWPerhaps extra scrutiny for RTW
Nurse case manager involvementNurse case manager involvement
Can’t do selective FFDs by DxCan’t do selective FFDs by Dx
Equipment safety and checksEquipment safety and checks
Visibility Visibility
Tools, maneuverabilityTools, maneuverability
Risks for reinjuryRisks for reinjury
Lift Assist Team @ DukeLift Assist Team @ Duke
Nurses, aides have Nurses, aides have high back injury rateshigh back injury rates
Staff plus equipment Staff plus equipment added to high risk added to high risk areas @ Dukeareas @ Duke
WC claims 50%WC claims 50%
Restricted Days 36%Restricted Days 36%
© Arjo, Inc.
Days missed or restricted with 6 Days missed or restricted with 6 Nutritionist Visits per yearNutritionist Visits per year
source: Wolf et. al., JOEM, Volume 51(2): 139-145 (Feb. 2009)
Future Trends…Future Trends…
Behavioral EconomicsBehavioral Economics
Legal Tests of WellnessLegal Tests of Wellness
Benefits CoordinationBenefits Coordination
ErgonomicsErgonomics
Job AnalysisJob Analysis
Broader cultural goalsBroader cultural goals
Societal interventionSocietal intervention
Employer-based health care?Employer-based health care?
Questions?Questions?
Brian J. Caveney, MD, JD, MPHBrian J. Caveney, MD, JD, MPH
Duke University Medical CenterDuke University Medical Center
[email protected]@duke.edu