Harris J S
American College of Occupational and Environmental Medicine's Committee on Practice Guidelines, Arlington Heights, IL, USA.
J Occup Environ Med. 1997 Jan;39(1):23-34. doi: 10.1097/00043764-199701000-00007.
The development and use of practice guidelines, if framed as recommendations for best practices in the prevention, diagnosis, treatment, and management of occupationally related health concerns and disability, can improve the quality of occupational medical practice and worker health and well being. Adherence to guidelines should improve the efficiency and effectiveness of prevention, care, and disability management by reducing the present wide variance in practices and then by moving the mean or median of process and outcome statistics toward recommended levels. The information developed for guidelines can also be used for patient discussion and expectation management. Practicing in evidence-based, agreed-upon ways should also make occupational medical practices more defensible. Guidelines should be explicit, be based on a review of the available evidence and benefits vs risks, have clear medical logic, link findings to diagnosis to treatment ot prevention, be time-based, and avoid recommending unproven approaches as a last resort. If possible, they should be reviewed and tested for usability. Guidelines that start with common occupational health concerns are best suited to prevention and outpatient care, because patients present in this way. The contents of a useful occupational health guideline would include a statement of purpose and scope, the method of development; the authors' and reviewers names and affiliations; an analysis of the specificity, sensitivity, and predictive power of mechanisms of illness or injury, symptoms, signs and tests; findings that point to a serious or emergent condition requiring immediate referral or treatment; diagnostic criteria; and initial treatment, including work with the patient in a therapeutic partnership. The guideline should also present information on factors known to be associated with work, and predictors of delayed recovery. Disability-duration statistics and methods of matching job requirements with worker abilities are also helpful. Guidelines should then outline reassessment of those patients whose health concerns remain after a reasonable recovery period. The recommendations should again be evidence-based and conform to the other attributes listed above. A discussion of management after reassessment, including behavioral referral, further testing, and procedures, is also quite useful. Recommendations for restoration of function and return to work complete guidelines focused on diagnosing, treating, and resolving activity limitations among workers. Simply developing and publishing guidelines has not resulted in improvement in practice. However, if used as the basis for peer-group interactions and actions by occupational health opinion leaders, guidelines can contribute to marked improvements in quality, worker satisfaction, and worker health.
实践指南的制定与应用，若将其构建为预防、诊断、治疗以及管理职业相关健康问题和残疾的最佳实践建议，便能提升职业医疗实践的质量以及劳动者的健康与福祉。遵循指南应能通过减少当前实践中广泛存在的差异，进而将过程和结果统计的均值或中位数朝着推荐水平推进，从而提高预防、护理及残疾管理的效率与效果。为指南所开发的信息还可用于与患者的沟通以及期望管理。以循证且公认的方式开展实践，也应能使职业医疗实践更具合理性。指南应表述清晰，基于对现有证据以及收益与风险的评估，具备清晰的医学逻辑，将检查结果与诊断、治疗及预防相联系，具有时效性，并且避免在万不得已的情况下推荐未经证实的方法。如有可能，应对其可用性进行审查和测试。从常见职业健康问题入手的指南最适用于预防和门诊护理，因为患者通常以这种方式就诊。一份实用的职业健康指南的内容应包括目的和范围说明、制定方法、作者及评审者的姓名和所属机构、对疾病或损伤机制、症状、体征及检查的特异性、敏感性和预测能力的分析、指向需要立即转诊或治疗的严重或紧急情况的检查结果、诊断标准以及初始治疗，包括与患者建立治疗伙伴关系。该指南还应呈现已知与工作相关的因素以及恢复延迟的预测指标的信息。残疾持续时间统计以及将工作要求与劳动者能力相匹配的方法也很有帮助。指南随后应概述对那些在合理恢复期后仍存在健康问题的患者的重新评估。这些建议同样应基于证据，并符合上述其他特性。重新评估后的管理讨论，包括行为转诊、进一步检查及程序，也非常有用。关于功能恢复和重返工作的建议完善了专注于诊断、治疗及解决劳动者活动受限问题的指南。仅仅制定和发布指南并未带来实践的改善。然而，如果职业健康意见领袖将其用作同行间互动及行动的基础，指南便能显著提升质量、劳动者满意度以及劳动者健康。
