Novokuznetsk State Institute of Postgraduate Medicine,

Novokuznetsk, Russia

 

During early 90s the sudden alteration in the policy resulted in closing down of the great amount of industrial enterprises of the former Soviet Union. In the end of 20^th century in Kemerovo region, a high urbanized region, thousands of persons with occupational injuries lost both compensatory payments and ability for timely and qualitative necessary medicosocial rehabilitation services.

The solution for the long term crisis was found only with implementation (January, 2000) of the Federal Law #125, June, 24, 1998, “About the Necessary Medical Insurance against Industrial Accidents and Occupational Diseases”. But it is too early to talk about solution of the problems in complex rehabilitation for industrial accident victims. According to the data from Russian Statistics Committee, the Kemerovo region’s population has been decreasing for more than 20 years. In 1992 the population size was 3 million 98 thousand people. In 2005 this number was 2 million 855 thousand people, in 2008 ‒ 2 million 833 thousand, in 2010 ‒ 2 million 765 thousand. In 2013 the population size decreased to 2 million 734 thousand. According to 01.01.2012 the proportion of employees in the regional economics was 45.4 % including 22.2 % in the industrial field [9].

The Kuzbass demographic rates stabilized after 2000s. The birth rate was 8.9 for a thousand of population in 2000, 10.5 in 2003, 11.3 in 2006, 13.3 in 2009, 13.7 in 2012. The mortality rates are still high, with decreasing only from 2007: 16.5 in 2000, 16.8 in 2001, 17.3 in 2006, 16.6 in 2007, 15.9 in 2009, 15.5 in 2011,  15.1 in 2012. The migration inflow is relatively insignificant ‒ 6.5-7.5 thousand people. During the recent years the number of individuals with the first acknowledged disability has been decreasing: in 2009 disability was acknowledged in 27,400 Kuzbass individuals, in 2010 ‒ in 21,900, in 2011 ‒ in 16,700, in 2012 ‒ in 17,500. Annually in the region the repetitive disability is found in 35,000 (2010) ‒ 32,500 (2012) adult persons [1-8]. According to 01.01.2013, the total number of disabled retired persons was 261,000. After Rostov region, Kuzbass takes the second place according to the number of insurance payments for industrial injuries and occupational accidents (about 35,000 persons). The rates of industrial accidents have been decreasing during the recent years: 2,800 persons in 2009, 2,500 in 2011.

The multiformity of traumatic injuries included locomotorium injuries as the most common ones ‒ 67.3 % in 2009, 62.5 % in 2010, 60.1 % in 2012. Polytrauma took the second place: 11.4 % in 2009, 17.1 % in 2012. The third place was associated with skin and soft tissue injuries ‒ 13.6 % in 2009, 10.2 % in 2010, 12.6 % in 2012. The proportion of traumatic brain injuries was 6-7 %. The proportion of primary disability from labour injury was 2.4-2.5 % for 10,000 of population in the beginning of 2000s. During the last years this rate is 1.5-2 % of all persons who were recognized as disabled for the first time. The absolute amount of such persons has been decreasing. 304 persons became disabled in 2009, 341 in 2010, 250 in 2011, 194 in 2012. The disability as result of locomotorium injury was identified in 251 persons in 2009, 299 in 2010, 190 in 2011, 170 in 2012 [6, 8]. The greatest amount (92 %) of persons with  the first disability after labor injury were at working age, 43 % of the persons were at the most active age ‒ 18-44.

The structure of primary disability in the victims with industrial injuries was in 2009-2012 as following: the first group of disability in 1.6 % in 2009 and 5.2 % in 2012, the second group of disability in 22.7 % in 2009, 20.1 % in 2012, the third group in 75.7 % in 2009 and 74.2 % in 2012. In 2012 the first group of disability after home injuries was identified in 9.6 %, the second group ‒ in 25.3 %, the third group ‒ in 65 %. In 2012 the severity of disability was distributed as following: the first group in 20.2 %, the second group in 34.7 %, the third group in 45.1 %. Therefore, there is a significant variation in distribution of disabled persons with firstly identified disability according to severity after labor injuries, home injuries and all causes. In firstly identified disability the small proportion of disabled persons of the group 1 is observed (3-5 %). The number of disabled persons with the group 2 is 20-23 % that is significantly lower than in all firstly recognized disabled persons. The main difference is associated with disabled persons of the group 3. The proportion of disabled persons of the group 3 is 74-75 % after industrial accidents. It is much higher than in disabled persons with home accidents ‒ 64-65 %, and almost two times higher than in all firstly recognized disabled persons ‒ 45-46 %. Therefore, successful rehabilitation is possible for the great amount of primary disabled persons of the group 3 after industrial accidents ‒ 75 % [4, 6, 8, 9].

It is assumed that the main criteria for effective rehabilitation of disabled persons in Russia are the indices of full or partial rehabilitation and burdening disability. We should point that full rehabilitation is the percent relation between persons with non-defined disability after rehabilitation and general amount of reexamined disabled persons. Partial rehabilitation is percent relationship between disabled persons of groups 1 and 2 who passed into easier group and general amount of reexamined disabled persons.

Burdening disability is a percent relationship between disabled persons who are shifted to more severe disability group because of increasing limitation of life activity and general amount of reexamined disabled persons. We present the table of comparative estimation of rehabilitation in Kemerovo region (table 1).

Table 1
Comparative estimation of rehabilitation values in Kemerovo region

Rehabilitation efficiency value	Full rehabilitation of disabled persons				Partial rehabilitation of disabled persons
	2001	2002	2011	2012	2001		2002	2011	2012
Reinspected disabled persons with consequences of home accidents	4.3	5.3	5.2	6.9	26.4		31.2	28.7	30.1
Reinspected disabled persons after industrial injury with consequences of locomotorium injuries	3.6	4.3	7	2.9	17		16	16.9	30

It is known that patients with consequences of locomotorium injuries are the most perspective and favorable category for complex rehabilitation. Industrial accident victims have additional financial provision for medical rehabilitation including health resort treatment. Comparative assessment of full rehabilitation in disabled persons after labor injury and home injuries to locomotorium testifies the similar low values of 5-7 %. Moreover, despite of significant volume of financing for medical assistance for victims with labor injuries, the values of partial rehabilitation are significantly lower than after home accidents (table 2).

The table 2 shows that low values of full and partial rehabilitation are associated with significant number of disabled persons with annual increasing disability degree. Among all reexamined disabled persons they were 13-15 % in 2009-2012. In disabled persons with consequences of home injuries the burdening of disability group is observed in 4-7 %. In disabled persons after labor injury the burdening is rare (2-3 %) [4, 9].

Table 2
Estimation of increasing disability severity in Kuzbass (%)

Increased disability severity	Years
	2009	2010	2011	2012
Increasing disability degree in all reinspected persons	12.4	15.3	13.4	12.7
Increasing disability degree in reinspected persons with home injuries to  locomotorium	4.4	5.8	7.2	6.7
Increasing disability degree in reinspected persons with industrial injuries to locomototium	1.9	3	3.1	1.8

The additional financing for medical rehabilitation is quite high in Kuzbass: inhospital and outpatient treatment, health resort, Topaz rehabilitation center. The average price of additional treatment for one patient was 95,300 roubles in 2009, 128,200 in 2010, 111,500 in 2011, 125,800 in 2012 [4, 9].

What the cause of low results of rehabilitation measures? The literature analysis [3, 4, 9] showed the main problems limiting efficiency of medicosocial and professional rehabilitation of patients with severe consequences of industrial injuries. Some authors [4, 9] think that the existing regulatory framework is improper and it does not provide timeliness and completeness of rehabilitation measures.

The new edition of the order by Ministry of Health and Social Development of Russian Federation #160 from 24.02.2005 “About definition of degrees of health damage after industrial accidents” abolished one of the main qualifying signs of health severity damage ‒ duration of timely disablement more than 60 days. At the same time, the list of severe injuries decreased. So, closed fractures of long bones (humerus, femur, tibia), including intraarticular ones, are related to mild accidents.

Considering the fact (according to the Federal Law #118 from 07.07.2003) about treatment of an insured person, which is paid by the Fund of Social Insurance, from the moment of severe accident to working capability restoration or disability estimation, it is clear that medical rehabilitation for patients with mild injuries is realized only with the means from obligatory medical insurance. The negative result of this regulatory act and “The Regulation for Payment of Additional Costs for Medical, Social and Professional Rehabilitation of Insured Persons with Health Damage after Industrial Accidents and Professional Diseases” (confirmed by the order by the Government of Russian Federation from 15.05.2006, # 286) are late terms of making decision about severity of an industrial injury and significant number of wrong decisions. According to the data from the Kuzbass regional department of Social Insurance Fund [4], 36.3 % of victims with health damage defined as “mild” became disabled. The mean term of the federal contract for costs of restorative treatment was 73.8 days in 2010. The early and productive stages of medical rehabilitation remain without additional financing in some persons with industrial accidents. It provokes inevitable conflicts and legal proceedings.

Another legislative problem is “Criteria for estimation of occupational capacity loss as result of industrial accidents or professional diseases”. During many years the specialists of medicosocial expertise had been indicating the imperfection and contraindications in the regulatory documents [2, 7]. Appeals of decisions about occupational capacity loss became common events in all region of the country.

In Irkutsk region [2] the judicial practice exists where the courts ignore the regulatory methodological principles and criteria for estimation of lost functions and labor activity, and, the main thing ‒ a possibility for changes during rehabilitation measures. The courts recommend 100 % definition of occupational capability loss in all patients who lost their ability to perform the professional activity, which they produced before an insurable event. Although all patients could continue their labor activity (including high qualification employment), the authors indicate that such approach is associated with dependency and it frustrates appropriateness of rehabilitation measures in persons of young, working age.

Considering the fact that almost 90 % of patients were at economically active age, it was not clear why many disabled persons stopped their work. There was a survey of 273 industrial accident disabled persons in Novokuznetsk Scientific Practical Center of Medicosocial Expertise and Rehabilitation for Disabled Persons [Muflikhunova N.T.]. Among them, 28 % were disabled persons of group 1, 50 % ‒ group 2, 22 % ‒ group 3. 68 % of the persons were age of 20-40, 32 % ‒ 41-50.

Only 13 % of disabled persons (4.7 %) had high educational level. All of them continued their occupational activity after medical rehabilitation. 260 (96.3 %) disabled persons were of working specialties. During the first year after trauma 158 (58 %) persons had positive orientation to labor. 2-3 years later the survey showed that 31 % of them had registered in an employment service, 38 % of unemployed persons completed training courses and graduated from specialized educational facilities. After 4 years the survey included 134 persons. Only 48 % of disabled persons continued their labor activity. It is necessary to note that 80 % of the persons, who registered in employment service, refused from offered positions. It was noted that over the time the rental attitudes became significant in disabled persons, but previous labor motivation disappeared. One could suppose that the low educational level and, simultaneously, sufficient retirement payment and compensation payment for health loss develop conception about negative influence of medicosocial and professional rehabilitation on their financial situation [5].

 

CONCLUSION

1. The rates of industrial accidents and resulting disability are one of the highest in Russia.

2. The efficiency of rehabilitation for disabled persons (after industrial accidents) are significantly lower compared to home injuries, despite of additional financing from Financial Insurance Fund.

3. The present regulations for estimating severity of health damage and occupational capability loss complicate timely and qualitative rendering rehabilitation services and require revision.

4. Many disabled persons with consequences of industrial injuries demonstrate dependency positions and absent desire to continue their labor activity.

5. It is necessary to develop and implement the algorithm for clinical rehabilitation of victims after industrial accidents in Kuzbass.