CDS Connect: Occupational Factors Impacting Diabetes

Occupational Factors Impacting Diabetes

Description

This artifact presents the National Institute for Occupational Safety and Health (NIOSH), Association of Occupational and Environmental, Diabetes subject matter expert (SME) group's recommendations (2015) for practitioners and patients regarding educational materials for working diabetic patients with jobs that entail factors which might impact the control of their diabetes, specifically: shiftwork; temperature extremes; heavy physical activity; and difficulty taking medications or eating regularly. It additionally identifies safety sensitive activities (i.e., scenarios where incapacitation of the employee performing these activities in a job could place the employee or others at risk of harm).

Creation Date
Version
0.1.0
Status
Experimental
True

Artifact Creation and Usage

Contributors

Allen, A, Welch, L, Kirkland, K, et al. Development of a Diabetes Mellitus Knowledge Resource for Clinical Decision Support Assisting Primary Care Physicians With Work-Related Issues. J Occup Environ Med. 2017;59(11): e236-e239.

IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Repository Information
Approval Date
Publication Date
Last Review Date
Knowledge Level

Structured code that is interpretable by a computer (includes data elements, value sets, logic)

Purpose and Usage
Purpose

Presents educational materials for practitioners and patients regarding issues with work schedules and work conditions that could put a diabetic patient at compromise, specifically shift work, temperature extremes, heavy physical activity, difficulty taking medications or eating regularly, and safety sensitive activities.

Intended Population

Working individuals with a diagnosis of diabetes

Usage

Intended for primary care providers (however, it is pertinent to any specialist treating a diabetic patient)

Cautions

The SME Group "...could not find a guideline that specifically addressed management of diabetes during shift work.  The guidance provided is based on an understanding of factors that raise or lower blood sugar and that impact a person’s use of insulin, such as physically demanding work, circumstances that increase cortisone output, or lack of food during periods of low blood sugar."  The SME Group "...utilized what we know about factors present at work to provide guidance for management of a patient with diabetes working in those environments" (CDC/NIOSH 2015).

The recommendations do not include all work scenarios (e.g. works two jobs that include shift work, works full time and then a part-time job, summer work only).  They do not specify other variables such as the degrees of temperature extreme, length of exposure, specific criteria for heavy physical activity, or list all safety sensitive jobs.

This artifact was developed to demonstrate how CDS expressed using HL7 standards can facilitate interoperability. As such, it is one of several components of the Value-Based Care Use Case exhibited in the 2018 HIMSS Interoperability Showcase. To meet strict deadlines for the Showcase, this artifact expresses only a small portion of the overall Occupational Factors Which Impact Diabetes guideline (i.e., evaluation of occupational factors to determine if education materials are indicated). Subsequent versions of the artifact will likely include a broader expression of the care algorithm as depicted on page 11 of the attached guideline.

Note: At present, codes depicting the five "occupational factors" in the CQL expression (e.g., shift work) are placeholders. The temporary codes will be replaced with permanent, standardized codes once comprehensive study of the source guideline by Georgia Tech Research Institute concludes in May 2018.

Please be aware that this artifact is in a very early draft state and has not been tested in a live clinical setting. Careful review is advised as additional refinements may be indicated.

Supporting Evidence
Source Description

Derived from the NIOSH, Diabetes SME Group's Final Knowledge Resource Report, titled "Using Electronic Health Records and Clinical Decision Support to Provide Guidance on Occupational Factors Which Impact Diabetes: A Final Knowledge Resource Report" (CDC/NIOSH 2015)

The report addresses:

  • The management of diabetes when a patient has workplace factors such as shift work, temperature extremes, exertion variances and time limitations (for medication and proper meals) that can affect blood sugar 
  • How impairment of physical or mental function due to hypoglycemia may impact patient or public safety
  • Guidance that exists for work restrictions for individuals with diabetes
References

National Institute for Occupational Safety and Health, Association of Occupational and Environmental, Diabetes subject matter expert group.  December 4, 2015. Using Electronic Health Records and Clinical Decision Support to Provide Guidance on Occupational Factors Which Impact Diabetes: A Final Knowledge Resource Report. Produced under CDC/NIOSH contract 212-2014-M-59011. 

Allen, A, Welch, L, Kirkland, K, et al. Development of a Diabetes Mellitus Knowledge Resource for Clinical Decision Support Assisting Primary Care Physicians With Work-Related Issues. J Occup Environ Med. 2017;59(11): e236-e239.

Recommendation

The NIOSH Diabetes SME Group recommends that primary care providers ask their diabetic working patients about occupational factors (i.e., conduct an Occupational Factors Assessment) if they:

  • Demonstrate a "not-at-target" HgbA1C (HgbA1C ≥ 8) OR

  • Demonstrate symptomatic hypoglycemia (defined as an event during which typical symptoms of hypoglycemia are accompanied by a measured plasma glucose of less than or equal to 70mg/dL) OR

  • Demonstrate serious hypoglycemia (a situation requiring help from a third party)

The assessment includes factors that impact diabetes management (i.e., shift work, exposure to heat or temperature extremes, ability to eat/drink/take medication as needed, and level of physical activity), along with evidence that the patient is engaged in a safety sensitive activity (i.e., where incapacitation of the employee could place the employee or others at risk of harm). Examples of safety sensitive activities/professions include firefighters, police officers, locomotive engineers, and commercial truck drivers. (CDC/NIOSH 2015).

If the response is "yes" to any of the five occupational factors, relevant educational materials should be selected by the provider and printed for the patient.

Strength of Recommendation

Grade B based on American Diabetes Association (ADA) of
• Supportive evidence from well-conducted cohort studies
• Evidence from a well-conducted prospective cohort study or registry
• Evidence from a well-conducted meta-analysis of cohort studies
• Supportive evidence from a well-conducted case-control study

Diabetes Care (January 2018).  Introduction: Standards of Medical Care in Diabetes 2018.  41: (Supplement 1): S1-S2. Retrieved from http://care.diabetesjournals.org/content/41/Supplement_1

Quality of Evidence

Aggregate Evidence Quality: B
Diabetes self-management is supported by a Grade "B" recommendation from the ADA

Diabetes Care (January 2018).  Introduction: Standards of Medical Care in Diabetes 2018.  41: (Supplement 1): S1-S2. Retrieved from http://care.diabetesjournals.org/content/41/Supplement_1

Artifact Decision Notes

A log of decisions made while translating and specifying this artifact is available in the Miscellaneous File section of this artifact (i.e. NIOSH Occupational Factors Impacting Diabetes Decision Log).

Artifact Representation
Inclusions

Currently this CQL does not specify inclusions but its intent is to determine if any of the occupational factors below are present in working diabetic patients

  1. Shift work
  2. Temperature extremes
  3. Heavy physical activity
  4. Difficulty taking medications or eating regularly
  5. Safety sensitive activity
Exclusions

None

Interventions and Actions

NOTE: This artifact was developed to demonstrate how CDS expressed using HL7 standards can facilitate interoperability. The artifact expresses only a small portion of the overall Occupational Factors Which Impact Diabetes guideline (i.e., evaluation of occupational factors to determine if education materials are indicated). Subsequent versions of the artifact will likely include a broader expression of the care algorithm in the guideline.

After assessing the patient’s recorded responses to the five questions concerning occupational factors, DISPLAY:

1) If a YES response to one or more occupational factors:
A list of educational materials to potentially print and provide to the patient.  This list will contain only those materials deemed relevant based on the patient's responses. The educational materials include information pertinent to each specific environmental factor, address potential work restrictions, and provide information about the American with Disabilities Act.

2) If a response is missing for one or more occupational factors questions:
ERROR: At least one occupational factors response was missing

3) If a response is more than six months old for one or more occupational factors questions:
WARNING: At least one occupational factors response is more than 6 months old and should be re-assessed

Rationale:  The National Institute for Occupational Safety and Health, Association of Occupational and Environmental, Diabetes subject matter expert (SME) group (2015) determined factors that might impact the working diabetic patient's ability to control their diabetes or the safety of the patient/others.   If there is no date for a factor being assessed or the assessment is greater than 6 months old, the clinician is alerted. 

Testing Experience
Pilot Experience

This artifact is in an early draft stage. It has not undergone testing in a clinical environment.