Agreement of medical decisions in occupational health as a quality requirement

Objective: Workers' medical examination by the occupational physician (OPs) is a decision-making process whose output consists of a variety of evaluations, including assessment of fitness for work. The medical literature reports that there is no complete agreement among OPs assessing the same workers, evidencing a critical aspect of professional performance. This study aims at evaluating the inter-individual variability of medical decisions by different occupational physicians. Methods: Four specialists in occupational medicine participated in the study. Each specialist examined 100 records of subjects with different medical conditions selected from about 2,500 health care workers. Each physician completed a form including the following items: assessment of fitness for work, advice to workers, need of further investigations, report of occupational disease, recommendation for the general practitioner. To assess the inter-individual variability the percent agreement and the agreement strength or Cohen's kappa were measured. Results: The study shows a variable agreement in the assessment of fitness for work among different professionals, with percent agreement ranging from 58% for the whole group to an average of 77% for physicians' pairs. By taking into account the variability expected by chance, the agreement ranged from fair to substantial. The agreement of other decisions (workers' advice, referral to other specialists, request of further investigation, report of occupational disease, recommendation for the general practitioner) was more variable. Conclusion: The study shows that an inter-individual variability exists for some decisions taken by OPs. According to the need to continuously improve professional practice, in the absence of qualitative standards based on the outcome, reduction of inter-individual variability that should be considered as a quality requirement of the performance of the occupational physician.