Occupational Health Services, Office of Patient Care Services, Veterans Health Administration, Washington, DC.
War Related Illness and Injury Study Center, East Orange VA Medical Center, East Orange, NJ.
Occup Med (Lond). 2017 Dec 30;67(9):718-721. doi: 10.1093/occmed/kqx158.
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).
To describe the characteristics of complex cases referred for OEM subspecialty evaluation and variation by referring provider's training.
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.
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.
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.
定性分析可为医疗保健领域的学习型组织提供重要经验教训。很少有研究将这些技术应用于职业和环境医学（OEM）领域。
描述 OEM 专科评估中复杂病例的特征以及因转诊医生培训而异的情况。
使用混合方法，我们对国家 OEM 远程咨询服务提交的临床病例进行了内容分析。筛选了 2014 年 4 月至 2015 年 7 月间连续输入的病例，并对其进行编码和分析。
108 例病例可用于分析。当地退伍军人健康管理局（VHA）非专家医生在接诊时 96%的病例中输入了主要医疗诊断。OEM 专科医生根据自由文本注释对重要医疗条件进行编码。编码员间的信度为 84%。非专科医生最常与三级 OEM 转诊相关的医疗诊断类型是内分泌（19%）、心血管（18%）和心理健康（16%）。在 1%的病例中提到了对使用控制或镇静药物的担忧。与转诊非专科医生相比，OEM 医生更有可能将病例复杂性归因于肌肉骨骼（OR：2.3，1.68-3.14）或神经（OR：1.69，1.28-2.24）疾病。药物使用（OR：2.2，1.49-2.26）更有可能成为转诊医生关注的临床原因。
这些发现突出了员工患者临床实践中 OEM 医师专科转诊的触发因素范围。本研究结果可用于为职业医学从业者提供教育、标准化临床实践路径以及质量审查活动提供信息。
