Newcomb, Richard D. MD, MPH; Molella, Robin G. MD, MPH; Varkey, Prathibha MBBS, MPH, MHPE; Sturchio, Glenn M. PhD; Hagen, Philip T. MD, MPH; Cha, Stephen S. MS; Buchta, William G. MD, MS, MPH
* Review the evolution of the pre-placement examination, including the impact of the Americans with Disabilities Act and the evidence regarding the benefits of pre-placement exams.
* Outline the development and evaluation of an occupationally focused questionnaire as an alternative to occupational exams at the Mayo Clinic.
* Summarize the findings of the evaluation and how the new questionnaire has affected the need for pre-placement exams.
Health-related examinations of prospective employees in the United States have included preemployment examinations done prior to a job offer and preplacement examinations done after a formal job offer. Prior to 1990, preemployment and preplacement examinations were conducted to accomplish a variety of goals. Although primarily intended to determine whether prospective employees were able to safely work in the position offered, they also served as a tool for employers to reduce the number of prospective employees with preexisting medical conditions and disabilities that potentially would result in high costs to the employer in the form of future on-the-job injuries, workers' compensation disability costs, and non–work-related medical conditions that may disable the employee. In addition to these occupational goals, some employers offered health evaluations that had an additional focus on health promotion.
In 1990, Title I of the Americans with Disabilities Act (ADA) made it illegal for employers to use preemployment medical examinations to discriminate in hiring on the basis of health issues.1 This completely altered the prevailing practice of conducting preemployment health examinations. Pre-offer medical inquiries are prohibited. This includes all disability-related inquiries and medical examinations, even if they are related to the job. Once an employee has been working, medical examinations must be job related and consistent with business necessity. It is only during the postoffer and prework phase that an employer may require any medical evaluation and make disability-related inquiries. Employers may make any reasonable inquiries regardless of whether they are related to the job, as long as it does so for all entering employees in the same job category. Although the ADA allowed for quite a bit of latitude in the content of the preplacement examination, it severely limited the cases for which such an examination would lead to an individual not being qualified for the job as offered.
Numerous studies and a Cochrane evidence-based review have concluded that comprehensive, physician-based preplacement examinations are of questionable benefit to prospective employers and applicants.2–5 However, these studies were not in health care settings and primarily were looking at whether medical testing and diagnosis was of benefit to either the employer or employee. When preplacement examinations are conducted, studies have suggested that health assessments be limited to individuals working in jobs that involve “hazardous environments, require high standards of fitness, or are required by law or when the safety of other workers or of the public is concerned.”2 Specialized employers may have additional requirements for prescreening that are specific to the risks for the work environment or to meet administrative requirements. For example, health care employers require screening for susceptibility and presence of infectious disease that can be treated or prevented, such as tuberculosis and rubella, and transportation industries may have specific regulated examinations for drivers or pilots.6,7
Throughout the United States, preplacement examinations have changed in character as companies seek the most cost-effective interventions for the earlier-stated objectives. Although there have been studies predating the passage of the ADA policies evaluating the benefit of comprehensive physician-based preplacement examinations, these studies have looked at the comprehensive physical examination along with additional diagnostic studies and determined that these did not add value to the preplacement process.2,8,9 There are no studies evaluating the usefulness of an occupationally focused questionnaire to supplant an occupational examination in health care institutions. The objective of this study is to determine if, in a health care setting, preplacement screening based on an occupationally focused questionnaire could achieve the same outcomes as a questionnaire-based screening in conjunction with an occupational examination by a physician or midlevel provider in compliance with ADA requirements.
MATERIALS AND METHODS
Approval for this retrospective study was obtained from the Mayo Clinic institutional review board.
In July of 2002, our institution changed the preplacement evaluation process. We discontinued routine laboratory testing and medical records review and created a function-based occupational questionnaire that was developed and approved by a broadly represented task force and institutional legal counsel. As part of the implementation process, a study was undertaken to evaluate the effectiveness of the questionnaire. All preplacement applicants seen in the occupational medicine clinic between December 1, 2003, and January 31, 2004 were considered eligible for the study. Individuals with a positive urine drug screen terminated the employment process before an occupational examination was completed and were not included in the analysis. For purposes of the study, we compared recommendations on the same patient at the end of a review of the occupational history versus recommendations at the end of a focused occupational examination by the same provider. During the occupational evaluation providers were allowed to access any available information, including the electronic medical record, or request additional outside documentation. To address the question of the study, the medical providers (physician or nurse practitioner) were asked to note their recommendations as (a) whether the individual was qualified without restrictions, (b) qualified with restrictions, or (c) not medically qualified for the job. For simplification, results were categorized as two outcomes: no restrictions needed or other conclusions (restrictions recommended or not medically qualified). All applicants with an ADA qualified disability were recommended for hire with restrictions suitable to each individual's medical condition. Individuals were not medically qualified when active drug dependence or insufficient treatment for such dependence was determined by the examiner.
Pre- and postexamination recommendations were analyzed for disagreement. Statistical analysis was conducted using the Sign test for categorical parametric data to determine whether there was a statistical difference between conclusions based on the survey alone and conclusions based on survey and clinical evaluation by a health care provider. A 0 was assigned in the case of agreement, and a 1 was assigned when there was disagreement between the two recommendations. P < 0.05 was considered a significant disagreement.
Age, gender, and race were studied descriptively for those patients in whom there was disagreement before and after examination. Data from this period were also compared with data from the same period the year before, when the old process had been used, to assure that our study population was representative of the typical applicant seen in the institution.
A total of 179 preplacement examinations were conducted in the period between December 1, 2003, and January 31, 2004. Of these, seven applicants (3.9%) had incomplete or missing conclusions noted during the pre- or postexamination and were excluded from analysis. The remaining 172 applicants formed the study sample. One hundred nine (63.4%) of the study participants were women. The average age of the study population was 31 years (range, 19 to 70 years). The demographics of the study population and a comparison population from 1 year prior were not significantly different.
Table 1 provides a summary of providers' recommendations before and following the occupational examination. Following provider review of occupational history survey alone, only one of the 172 employees had restrictions recommended. In comparison, 163 (94.7%) were recommended to be hired without restrictions following provider review of the occupational history survey and occupational examination.
There were nine individuals not qualified or needing restrictions. For eight participants there were discrepancies between recommendations based on the occupational questionnaire alone versus the recommendations based on the questionnaire and occupational examination. The reasons not qualified for hire or needing restrictions are as described in Table 2.
One applicant (0.6%) was identified during physical examination as having had recent knee anterior cruciate ligament repair surgery and was recommended to be qualified for hire with restrictions. This individual had not revealed potential physical limitations for work on the survey. Another applicant was determined to be pregnant during examination by the medical provider and was given temporary lifting restrictions until the completion of pregnancy. Two other individuals (1.2%) had contact allergic dermatitis with latex use and were given restrictions to avoid latex use. One individual had red/green color blindness and was given restrictions of no work requiring color discrimination. Another individual was recommended qualified to work but with restrictions that they must observe infection control procedures (the individual had tinea corporis). Two individuals were identified with alcohol dependency at the time of the provider encounter through review of the electronic medical records. One had active alcoholism and multiple emergency department visits for the same within the pprevious few months. A second individual was actively participating in an early phase of a treatment program for alcohol dependence and was determined not to be in stable recovery at the time of examination. Both were disqualified based on interpretation of the ADA's criteria allowing for employers to exclude individuals from hire on these conditions. Of note, questions related to alcohol use had been inaccurately completed by the applicants in the occupational history questionnaire.
Use of the Sign test revealed statistically significant disagreement (P = 0.0078) between preexamination conclusions utilizing occupational history alone versus occupational history and examination. In these eight disagreement cases, five were women and they were younger than 40 years; all were white.
In a large medical center, there is typically a large diversity of jobs, job demands, safety concerns, confidentiality concerns, and potential job hazards. The assessment of a new employee should be tailored to these diverse needs in accordance with employment law and medical confidentiality. In this study of 172 employees, we found that there were statistically significant differences in the classification of new employees when comparing conclusions based on a functional occupational questionnaire alone with review of the questionnaire and medical records by a physician or midlevel provider in conjunction with a focused physical examination. This study suggests a finding contrary to previous publications and reviews2 questioning the value of the preplacement examination.
Studies that question the value of preplacement examinations often focus on the detection of medical conditions that could affect an individual employee's health and ability to work. Although significant medical conditions may exist in new employees, the preplacement screening process may not be the best or most appropriate place to discover and address such conditions. Flight et al10 reviewed the post-hire medical problems associated with a group of 402 consecutive health assessments (166 men, 236 women, age range <20 to 59 years) performed at an IBM headquarters location. In this study, medical policy required that 60 individuals seeking certain positions have a medical examination performed by a physician. Of the 342 nurse-based preplacement health assessments, 21 medical issues that had not been identified during the health assessment were found in the posthire review (86.6% more than 1 year of employment; 13.4% 6 months to 1 year of employment). It was determined that these 21 medical issues were not identified because the patient withheld information or the condition developed after they were hired, thereby supporting the use of nurse-based initial health assessments. Therefore, the authors concluded that it was not effective to utilize physicians to detect underlying medical conditions because of either an individual withholding known medical information or development of the condition during a follow-up period. In either circumstance, there was no resulting loss in any employee's ability to work safely.
We agree with Pachman2 that work in a health care system requires a higher level of scrutiny for the preplacement examination because health care workers must be able to work safely in “hazardous environments, may require higher standards of fitness to meet physical job demands, and must meet a higher level competence and ability when providing services for the public.” We found that the focused occupational examination was useful in finding eight individuals with conditions that would result in limitations in the applicants' ability to perform essential work tasks or would disqualify them from hire. The occupational examination helped to tailor a specific protective restriction for six individuals and disqualified two individuals with active substance dependence or an insufficient time frame after active drug use. Although there was statistical significance in finding these conditions, one may reasonably ask whether these were clinically significant for the large number of employees we hire each year and whether we could adapt a function-based occupational questionnaire to capture these individuals to minimize the use of physicians and midlevel providers. The number of new employees with disqualifying conditions, or with ADA qualifying disability, found by our preplacement screening and physical examination was very small (9 of 172, or 5.2%) and may indeed not justify the cost of the 163 occupationally negative examinations.
The study had impact on our occupational preplacement examinations. On the basis of our findings, we have altered our focused occupational screening to add a question regarding current pregnancy and any need for lifting restrictions in order to prompt the applicant to discuss the reason for the restriction. In fact, wording regarding any decreased function of knees already existed but received a negative response from the individual with the anterior cruciate ligament deficiency. Questions were present about latex allergies but were not recognized as requiring further discussion by the applicant in one instance and neglected for prescreening conclusions for a second individual. Although questions were already present regarding alcohol dependence, prior treatment, and stability of recovery, we added further questions to assist with screening, and further research would assist in determining whether these additional questions are sufficient to rely on the questionnaire alone to screen applicants.
Formal cost analysis was not performed as part of this study, but we estimate that for a hiring practice similar to this study, an average of 10 hours per week of provider time can be freed for other duties if occupational examinations are eliminated. Additional nursing time maybe required to review questionnaires, but this would be a fraction of the cost of using health care providers for this service and would allow nurses to develop further efficiency in the preplacement process. Currently, we continue with physical examinations only for applicants that respond positively to any inquiry on the questionnaire that might result in a recommendation for hire with restrictions or not medically fit for hire.
This study is not without limitations. Our study investigated the findings for preplacement examinations in a tertiary care health care institution in a Midwestern mixed urban and rural setting; therefore, it is possible that our findings are specific to health care settings and our local employment environment resources. Workplace tasks and potential hazards in other occupational settings may require a greater (or lesser) degree of physical evaluation that might be better suited for increased physician involvement. Additional limitations of the study were that examiners were the same for the focused occupational survey review alone as for the postreview, interview and examination, so potential bias could be a factor. Some of the original intentions of the preemployment examination were laudable and sound. Good health among employees is important both to them and to the company. Both health promotion/preventive activities and good disease management affect employees' general health, health costs, and productivity.11,12 Our current process of using a focused function-based occupational questionnaire, now administered by Occupational Health–certified registered nurses, provides basic advice about good health practices (not smoking, exercise, updating immunizations, etc.).
To compensate for the loss of the new employee entry General Medical Examination, access to robust primary care became more important. Over the past 10 years our institution has restructured primary care to allow for easy access to and tracking of preventive care. We have also developed an integrated worksite wellness program that incorporates self-care, telephonic nurse line, Web portal, and health promotion programs that are centered around a yearly health risk assessment. Future research is needed to evaluate the cost, value, and outcomes of an integrated employee process.
A well-designed questionnaire is useful for screening applicants for preplacement examinations and assures sufficient detail to allow for a large proportion of individuals to proceed to employment without a face-to-face examination. A small but clinically significant portion of applicants require face-to-face examinations, and further refinements in the questionnaire will allow for us to limit examinations to approximately 5% of our applicant pool.
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