Medical-Social Efficiency of Pre-Departure Medical Examination in Railway Transport

The dissertation of Vil'k Mikhail Frankovich, defended at the Russian State Medical University (Moscow), is dedicated to the development of a methodology for evaluating the medical-social and economic efficiency of pre-departure medical examinations (ПРМО) of locomotive crew workers in railway transport. The study analyzes the relationship between health status and functional activity indicators of locomotive crew workers and the occurrence of train accidents and collisions, and substantiates a system of indicators of the medical-social efficiency of ПРМО, taking into account the influence of organizational factors and the dynamics of the number of examinations. For the first time in the study, an approach to the comprehensive evaluation of the efficiency of pre-departure medical examinations was proposed and tested, including syndrome analysis of data from different railways and the development of a quick-reference qualimetric methodology that allows the conversion of qualitative indicators into quantitative ones for the operational evaluation of the results of preventive medical work.

Relevance of the Study. Within the complex of measures ensuring the safe operation of railway transport, an important role is played by the activities carried out by curative-preventive institutions of the Ministry of Railways of the Russian Federation. Among the principal preventive measures, priority, alongside control over compliance with sanitary and hygienic conditions, belongs to preventive medical examination [70, 71]. In railway transport, medical examination encompasses preliminary and periodic medical check-ups, as well as pre-departure control of locomotive crew workers. Each type of examination has a specific purpose and frequency of conduct [71]. The basic provisions, the procedure for examinations, and the requirements imposed on the health status of persons employed in railway transport are regulated by departmental documents: the "Regulations on the Procedure for Conducting Mandatory, Upon Employment, and Periodic Medical Examinations on Federal Railway Transport," introduced by Order No. 6Ts of the Ministry of Railways of the Russian Federation dated March 29, 1999, and registered by the Ministry of Justice of the Russian Federation on April 20, 1999, No. 211/1759. One of the most priority and widespread professions of railway transport, ensuring priority tasks of the railway industry — namely, the provision of train movement and freight transportation — is that of locomotive crew workers: drivers and assistant drivers. This professional category is also the most costly in terms of professional training; therefore, the preservation of health of locomotive crew workers is among the priority tasks of the medical services of the industry. Among the entire complex of medical measures carried out for locomotive crew workers, a special place is occupied by pre-departure medical examinations (ПРМО), conducted with the aim of early detection of acute and exacerbated chronic diseases, various deviations and functional impairments in health status, timely implementation of curative-preventive measures, detection of violations of work and rest regimes, and residual manifestations of alcohol consumption among workers reporting for a shift, among others. The special significance of ПРМО is due to the fact that these examinations are conducted most frequently, on the most widespread scale, and it is precisely these examinations that are most responsible for physicians, since an error in the assessment of a driver's condition is practically impossible to correct. According to data from the Central Office of Medical Examinations of the Department of Railway Transport of the Ministry of Railways of the Russian Federation, in 2001, pre-departure medical control was carried out for workers at 778 enterprises of the Ministry of Railways of the Russian Federation and 22 enterprises of railway transport construction and metro systems (under contractual conditions). Examinations were conducted at 59 polyclinics and 247 hospitals of the Ministry of Railways of the Russian Federation, within the structure of which ПРМО were carried out by 915 units (offices, ambulatories, health posts, first-aid posts, medical points, health posts of locomotive depots). In total, in 2001, 24,615,768 pre-departure medical examinations were conducted. Thus, the system of ПРМО represents a tremendous burden for the workers of medical support of railways and, in the opinion of V.A. Kudrin and A.A. Prokhorov (2000), requires significant expenditures — approximately 30% of all expenditures on sectoral healthcare [54]. The system of ПРМО ensures, to a certain extent, the preservation of the health of railway workers and members of their families, as well as enhances the attractiveness of the railway profession for workers and young people, which makes it possible to preserve the labor potential of the industry (V.A. Kaptsow, 1995; V.Z. Kuchenko et al., 2000; V.A. Kaptsow, S.V. Suvorov, V.B. Pan'kova, 1998; N.A. Zakharova, 2001) [27, 33, 35], which determines, at the very least, the basic factors of the medical-social and economic efficiency of the system of ПРМО (A.A. Prokhorov, V.A. Kudrin, 2000) [54]. The organization of ПРМО is carried out on the basis of the instruction designated by Order No. В-788-u of the Ministry of Railways of the Russian Federation, "On the Procedure for Organizing and Conducting Pre-Departure Medical Examinations of Locomotive Crew Workers," dated July 6, 1998, approved by the Ministry of Railways of the Russian Federation on May 1, 1998, No. TsUVS-552, and registered by the Ministry of Justice of the Russian Federation on June 23, 1998, No. 1541 [2]. The medical-social efficiency of ПРМО is currently determined by such indicators as: reduction of morbidity with temporary loss of capacity for work, development of profession-dependent health impairments, indicators of disability among industry workers, and others, which ultimately determine the extension of professional capacity of the labor potential of the industry, reduction of premature mortality indicators, and so forth. The economic component of the efficiency of ПРМО consists in the prevention of material damage from train collisions and accidents, cases of defects in special accounting in operations occurring through the fault of drivers. However, the economic effect from the prevention or reduction of payments for temporary and permanent disability, expenditures on treatment, rehabilitation measures, and employment of workers who have lost professional capacity, and, ultimately, the preservation of labor resources in railway transport, is of an indirect nature and does not yet have a unified methodology of evaluation. Furthermore, the list of these components is not entirely complete, and there are no adequate approaches to the economic evaluation of planned medical measures aimed at increasing the efficiency of ПРМО. Taking into account the significant economic expenditures for the conduct of ПРМО, the most complete and comprehensive evaluation of this work — directly its medical, social, economic, and possibly other components of efficiency — is a pressing task, for which it is necessary to determine the criteria for the efficiency of ПРМО and to develop the most informative methodology for their use in order to improve preventive work during the period of reforming railway transport in Russia. The goal of the study is the scientific substantiation and development of a methodology for evaluating the medical, social, and economic components of the efficiency of measures for preventive medical examination of railway transport workers (on the example of the efficiency of pre-departure medical examinations of locomotive crew workers). In order to achieve the stated goal, the following specific scientific tasks were addressed: 1. Determination of the share of influence of health indicators and functional state of the body of locomotive crew workers in train accidents and collisions. 2. Scientific substantiation and development of a system of indicators of the medical-social efficiency of ПРМО based on: 2.1. studying the influence of ПРМО on the health status of locomotive crew workers; 2.2. determining the relationship between the number of ПРМО and their efficiency indicators: indicators of professional incapacity, primary granting of disability, number of cases and days of temporary disability; 2.3. determining the influence of organizational factors on the indicators of efficiency of ПРМО. 3. Studying modern trends in the dynamics of indicators of efficiency of ПРМО, including through their syndrome analysis. 4. Development and scientific substantiation of a methodology for the economic efficiency of ПРМО taking into account the technical component. 5. Development and testing of a quick-reference methodology for evaluating the efficiency of ПРМО based on the use of principles of qualimetry. The scientific novelty of the study lies in the development of a new scientific direction in the methodology for evaluating the medical-social and economic components of the efficiency of measures for medical examination in railway transport. For the first time, a new approach to evaluating the medical-social and economic efficiency of pre-departure medical examinations of locomotive drivers in railway transport was proposed and tested, based on: — establishing the relationship between ПРМО indicators and the safety of train movement; — quantitative evaluation of certain qualitative indicators of ПРМО (dynamics of the number of examinations, staffing levels, rationalization of organizational questions of ПРМО, etc.); — determination of the dynamics of modern trends in the development of the system of ПРМО. Statistical and substantive substantiation was developed for the selection of indicators of the medical-social and economic efficiency of ПРМО, expanding their modern composition and directed toward increasing the significance of medical preventive examination in the safety of train movement. For the first time, a syndrome analysis of data characterizing the efficiency of ПРМО was carried out at different railways, making it possible to identify common positive or negative trends in the organization of medical preventive work and to determine directions for its improvement. The economic efficiency of ПРМО was determined taking into account the technical component. A scientifically substantiated methodology was developed and proposed for practical healthcare — a new method for evaluating the economic efficiency of measures for improving the existing ПРМО using qualimetric analysis, demonstrating their substantial significance, including during the period of railway reform. The practical significance of the work is determined by: — creating a methodological foundation for selecting the most economically efficient directions for the development of the system of ПРМО and developing normative and methodological documents for improving medical examination in railway transport; — establishing the most complete list of factors influencing the efficiency of ПРМО and determining the assessment of their relative importance; — developing project methodologies and, in particular, a quick-reference method for evaluating the medical-social and economic efficiency of the existing system of ПРМО, as well as measures for their improvement based on a qualimetric approach (conversion of qualitative indicators into quantitative ones). The main provisions of the dissertation work are reflected in the following directive and normative and methodological documents: Order No. 6Ts of the Ministry of Railways of the Russian Federation "On the Approval of the Regulations on the Procedure for Conducting Mandatory, Upon Employment, and Periodic Medical Examinations on Federal Railway Transport" dated March 29, 1999. Order No. 15TsZ of the Ministry of Railways of the Russian Federation "On the List of Medical Contraindications to Work Directly Related to Train Movement" dated November 5, 1999, approved by the Ministry of Health of the Russian Federation on October 29, 1999. Order No. 54 of the Ministry of Railways of the Russian Federation "On Amendments and Additions to the List of Medical Contraindications to Work Directly Related to Train Movement" dated December 29, 2001. Directive No. Йл-2278-u of the Ministry of Railways of the Russian Federation "On Medical Regulations for Admission to Work Directly Related to Train Movement and the Activity of Medical-Expert Commissions of Curative-Preventive Institutions of Federal Railway Transport" dated October 8, 1999. Directive No. 372pr-u of the Ministry of Railways of the Russian Federation dated October 11, 1999, announcing the Resolution of the Government of the Russian Federation No. 1020 "On the Approval of the List of Professions and Positions of Workers Ensuring Train Movement, Subject to Mandatory Preliminary, Upon Employment, and Periodic Medical Examinations" dated September 8, 1999; Regulations on the Register of Professional Diseases in Railway Transport, approved by Deputy Minister of Railways of the Russian Federation P.A. Shevtsikov on March 1, 2001. Instructional and Methodological Recommendations on Maintaining the Register of Professional Diseases in Railway Transport, approved No. TsUVSS-6/2 on February 20, 2001. Methodological Guidelines "Methodology for Evaluating Production-Professional Risk of Railway Workers Working under Conditions of Production Hazards Taking into Account Trauma Safety" of the Ministry of Railways of the Russian Federation, approved February 22, 2001, No. TsUVSS-6-/5. TESTING OF THE STUDY. The materials of the work were presented at: — the IX All-Union Congress of Hygienists and Sanitary Physicians. — Moscow, October 2001. — the International Conference "New Technologies for Ensuring Competitiveness and Quality of Goods and Services." — Moscow, October 31 — November 2, 2001. — the X Symposium "Qualimetry in Education: Methodology and Practice." — Research Center for Problems of Specialist Training Quality, Moscow State Institute of Steel and Alloys (Technological University). — Moscow, April 4-5, 2002. — the Exhibition-Conference "Modern Medicine in Ministries, Corporations, and Enterprises." — MMa named after I.M. Sechenov, Mye Medical-Proekt-Rodon, LLC InformTechExpo XI, Department of Healthcare of the Ministry of Railways of the Russian Federation, and others. — Moscow, April 11-15, 2002. — the Scientific and Practical Conference "Implementation of Modern Medical Technologies in the Field of Solving Problems of Health Protection, Prevention, and Treatment of Diseases" MMa named after I.M. Sechenov, Mye Medical-Proekt-Rodon, LLC InformTechExpo XI, Department of Healthcare of the Ministry of Railways of the Russian Federation, and others. — Moscow, April 12-13, 2002. The quick-reference methodology for evaluating the efficiency of pre-departure medical examination in railway transport was introduced into the practice of Central Clinic No. 6 of the Ministry of Railways of the Russian Federation, the branch hospital of St. Tula, Moscow Railway. Twenty-two works on the topic of the dissertation were published, including 7 sole-authored works in central publications, 3 in international publications, and monographs co-authored.