Medical-occupational rehabilitation of work-related dermatoses - optimizing and quality-management of an integrated interdisciplinary medical and educational programme of tertiary prevention

Status:

completed 07/2013

Aims:

Occupational skin diseases (OSD) have topped occupational diseases in Germany for years. Presently, approximately 25,000 new OSD cases are officially reported each year to the German Social Accident Insurance Organization (DGUV - the umbrella association of the accident insurance institutions for the industrial and public sectors). The disease burden is high not only for individuals but also for society as a whole. Estimated annual economic costs in Germany due to sick-leave and lack of productivity by OSD exceed €1.5 billion. Thus, in recent years, various pilot initiatives aiming to improve prevention of occupational skin diseases have been developed and evaluated. A corollary of this work is the nationwide DGUV multi-step intervention approach. This approach offers a tailored hierarchical concept of offers for quick preventive help at all levels of severity of OSD to affected workers. Concepts underpinning these preventive interventions include multidisciplinary skin protection teaching programs for high-risk professions. For cases of severe OSD, in which outpatient prevention measures are not sufficiently successful, specific multidisciplinary inpatient prevention measures have been developed (tertiary individual prevention, or TIP [“Osnabrueck Model”]). TIP represents the ultima ratio within the DGUV multi-step intervention. TIP comprises 2–3 weeks of inpatient dermatological diagnostics and treatment as well as intensive health- related pedagogic and psychological counseling. Furthermore, TIP includes occupational therapy for use tests of adequate skin protection methods in a simulation model of the workplace, counseling by the case manager of the statutory accident insurance bodies, and – wherever possible - involvement of the employer’s occupational physician. Subsequently, after discharge, the local dermatologist follows up the patient at short intervals for at least another 3 weeks, during which the patient is still out of work to allow full epidermal barrier recovery. Aim of the ROQ study was to develop criteria for a scientifically sound, quality assured standard procedure for TIP, and assess effects and sustainability of a standardized TIP- measure regarding the main target parameters course of skin disease, life quality, reduction of sick leave and job loss due to OSD, and cost-effectiveness.

Activities/Methods:

The study was carried out according to a detailed study protocol as a multicenter intervention study in 5 hospitals throughout Germany in n=1788 consecutive patients with severe OSD, mainly of the hands, who gave informed consent. The study was approved by the ethical committee of the University of Osnabrueck. After 6 weeks of work abstinence and before return to work the patients were dermatologically examined and counseled in the study centers to conclusively decide about their ability to work and for final adjustments. The patients were then further followed up by the centers 4 weeks after return to work, and 1 year and 3 years thereafter. In cooperation with the treating local dermatologists, follow-up intervals were shortened when necessary due to an unfavorable course of disease.

Results:

The ROQ study protocol was carefully executed in all 5 study centers, follow up was carried out meticulously in the patient cohort. Loss to follow up was minimal; participation between the 1 year and 3 year follow up was 90 %, compared to the inception of the study after 3 years participation rate was 82.5%. Intention-to-treat analysis revealed no significant differences between participants and non-responders. Within the 3-year observation period 97% were able to resume work after the TIP measure, and yet even after 3 years 83% were still working in some kind of profession, 70.6% were working in the same job (mostly with significantly changed skin protection behavior). Average sick leave for OSD was in the year before the measure 34.5 days, and was drastically diminished to a total of 9.1 days altogether for the second and third year of follow up. Furthermore, it could be demonstrated that by the TIP measure the severity of the skin disease and correspondingly the patients’ quality of life had markedly improved and that these effects remained essentially stable over the 3-year observation period. Acceptance by the participants for the measure, including the health-educational intervention, was high and this may explain for the low dropout rate. In the few cases where the TIP measure was not successful the provided detailed medical evaluation by the TIP centers allowed for swift and competent case management by the statutory accident insurance bodies.

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