Effect of on-site first aid for industrial accidents on healthcare utilization after primary medical care: A 4-year longitudinal study

doi:10.21203/rs.3.rs-2802508/v1

Objectives:

The number of industrially injured workers (IIW) is increasing in Korea. However, little research has been conducted on whether first aid is properly performed at industrial sites or on the association between first aid for industrial accidents and the prognosis of IIW, including healthcare utilization.

Methods:

A total of 3,092 participants (2,562 males and 530 females) were analyzed during the 4-year study period, which contributed to 11,167 observations. Healthcare utilization was evaluated based on the number of outpatient visits, hospitalizations, and duration of hospitalization. Several time-varying socioeconomic characteristics and information about the injury were adjusted, and transfer time to the emergency room was also considered.

Results:

During 4-year after the termination of primary medical care, participants who had not receive first aid visited outpatient clinics 15.243 times per year, and those who had visited 13.928 times per year, which is 16.16% less (adjusted relative risk [aRR]: 0.838, 95% CI = 0.740–0.950). Participants who had received on-site first aid with less than a 0.5-hour transfer time to the emergency room visited outpatient clinics 14.87% less per year than those who had not received first aid (aRR: 0.851, 95% CI = 0.750–0.966).

Conclusion:

To reduce the long-term outpatient utilization rate for IIW after primary medical care, on-site first aid must be provided in a timely manner. Employee education and first aid training are also necessary.

Occupational safety

Outpatient

Hospitalization

Industrial injured workers

PSWCI

According to the Occupational Safety and Health Act in Korea, industrial accidents is “any death, injury, or disease of a person who provides labor caused by structures, equipment, raw materials, gas, vapor, powder, dust, the other causes related to the duties, or by work or other duties” [1]. The percentage of industrial accidents per 100 workers in 2011 was 0.65%, and it remained almost the same in 2021 at 0.63% [2]. Meanwhile, the number of deaths due to industrial accidents was 2,114 in 2011 and 2,080 in 2021 [2]. The cumulative number of industrially injured workers (IIW) in South Korea has remained high; considering the non-reporting and concealment of accidents, the actual figure could be even higher [3].

It is essential to minimize the consequences of industrial accidents from the perspectives of victims and the government. In 2021, 23.5% of IIW received primary medical care for industrial accidents for more than 6 months and 60.8% of them were treated for 1–3 months [4]. IIW suffer from chronic sequelae and diseases such as pneumoconiosis, hearing loss, brain damage, and musculoskeletal diseases [5]. As a result, the amount of insurance benefits (medical care, temporary layoff benefits, disability benefits, nursing benefits, survivors’ benefits, injury and disease compensation pensions, funeral expenses, and vocational rehabilitation) has increased from 3.62 trillion South Korean won (KRW) in 2011 to 6.45 trillion KRW in 2021 [6].

Medical interventions for industrial accidents under government management include primary medical care at designated hospitals, long-term care, or medical rehabilitation [7]. It is well known that on-site first aid provided to accident victims by bystanders or rescue workers is a substantial intervention for a good prognosis when there are delays in the arrival of medical professionals and transfers to the emergency room [8–10]. However, there has been little research on whether first aid is properly performed at industrial sites. Further, the association between the provision of first aid for industrial accidents and the prognosis for IIW, including healthcare utilization, remains underexplored. Therefore, the primary objective of this study was to investigate the percentage of on-site first aid provision in the event of an industrial accident, focusing on industrial injuries and excluding occupational diseases and commuting accidents. In addition, this study analyzed throughout a 4-year period how on-site first aid is related to the rate of healthcare utilization (outpatient and hospitalization) after the provision of primary medical care for industrial accidents. Furthermore, a detailed effect based on the transfer time from the accident site to the emergency room was considered.

Study population and data

Panel Study of Workers’ Compensation Insurance (PSWCI) data from 2018 to 2021 by the Korea Workers’ Compensation & Welfare Service (KCOMWEL) were analyzed. The PSWCI is a nationwide annual panel study of industrial accident victims that collects data on industrial accident insurance coverage and socioeconomic characteristics after the termination of primary medical care. The PSWCI is administered by tablet-assisted personal interviews (TAPI) with a visitor interview. In total, 81,252 IIW terminated medical care between January and December 2017. In the PSWCI, 3,294 participants were included through proportional stratified random sampling based on disability grade (six categories), sex (two categories), age group (four categories), and systematic sampling based on area of residence (six categories) and rehabilitation service usage (two categories). At the initial stage of analysis, 202 participants were excluded because they did not answer several questions regarding the variables. As a result, 3,092 participants (2,562 males and 530 females) were analyzed and contributed 11,167 observations during the 4-year study period. As of 2021, 2,797 participants remained in the PSWCI (retention rate: 84.9%).

Measures

On-site first aid

The participants were asked whether they experienced appropriate on-site first aid by co-workers at the time of the industrial accident and the response items were “yes” or “no.” According to the Occupational Safety and Health Act, business owners are obliged to prevent industrial accidents and provide employees with information on safety and health at relevant places of business, including tips for first aid [1]. Therefore, the Korea Occupational Safety and Health Agency (KOSHA) provides professional tips for first aid according to the type of industrial accident [11]. For example, “Do not move the patient recklessly, and keep him/her in a comfortable position” is recommended as a general tip for fractured patients. In this study, industrial accidents involved accidents on duty, but not occupational diseases or commuting accidents.

Healthcare utilization: Outpatient and hospitalization

The participants were asked, “What is your history of visiting medical institutions in the past year?” Regardless of the reason for healthcare utilization, the number of outpatient visits, hospitalizations, and duration of hospitalization were evaluated. Pharmacies and nursing homes were excluded from the utilization count, and health checkups were excluded from the number of outpatient visits. Circuit outpatient visits were also excluded. For example, receiving treatment in more than two different departments at the same medical institution was only considered as one visit. If participants were admitted to the hospital for 365 days, and if they were admitted or discharged on the day of the emergency room visit, they were marked as hospitalized once.

Transfer time to emergency room

The participants were asked, “How long did it take for you to be transferred to the emergency room?” The transfer time to the emergency room was classified into four groups according to the PSWCI: less than 0.5 hour, 0.5 ~ 1 hour, 1–2 hours, and more than 2 hours.

Covariates

Several time-varying socioeconomic and health-related characteristics were adjusted. Patients were classified as either male or female. The age group was divided according to the PSWCI: age below 30s, 40s, 50s, and above 60s. Education level was divided into university or higher, and high school graduation or lower. Current economic activity was divided into employed, unemployed, and economically inactive. Current household income was divided according to the quintile of household income. Household income is the sum of earned, financial, real estate, and other income. Statistics Korea data for the entire population were used as the income quintile cutoff for each year [12]. Area of residence was divided into metropolitan and provincial (rural). Medical histories of chronic diseases such as cancer, hypertension, and diabetes before industrial accidents were divided into without chronic disease and with chronic disease. The types of injuries due to industrial accidents were divided into fracture, sprain, back pain/musculoskeletal disease, amputation, cuts, bruising/concussion, rupture/laceration, burns, and other (abrasions, stab wounds, frostbite, contagion/addiction, and internal organ damage). Disability grade was based on 14 levels of physical/mental aftereffects of industrial accidents designated by law after the termination of primary medical care and symptom fixation [1]. The higher the disability grade, the more severe the disability level. In the analysis, disability grade was divided into the following groups as given by the PSWCI: grades 1–3 (most severe), 4–7, 8–9, 10–12, 13–14, and no disability. The period of primary medical care, which refers to the initial acute management at the designated hospital for IIW, was divided into the following as given by the PSWCI: < 3 months, 3–12 months, and > 1 year. Variables including sex, age, area of residence, type of injury, disability grade, and period of medical care were administrative data from the KCOMWEL, while variables including education level, current economic activity, current household income, and past medical history before accidents were self-reported.

Statistical analysis

A generalized estimating equation (GEE) Poisson regression was applied for the analysis. Poisson regression with a log link function and an unstructured (UN) working correlation matrix, which had the lowest Quasi-likelihood under Independence Model Criterion (QIC) statistics, was used for the longitudinal data (from 2018 to 2021). The results are presented as adjusted relative risk (aRR) with 95% confidence intervals (CI). Subgroup analyses were conducted to determine the detailed effects based on transfer time to the emergency room and the covariates. As the variance inflation factors (VIF) for all variables were less than 1.6, there was no evidence of multicollinearity. Version 9.4 SAS software (SAS Institute, Cary, North Carolina, USA) was used. Statistical significance was set at P ≤ 0.05.

The general characteristics of the participants in 2018 are presented in Table 1. A total of 1,252 participants (40.5%) did not receive on-site first aid, while 1,840 participants (59.5%) did. The most common type of injury in the total population was a fracture (60.8%). More than half of the participants had either grade 13–14 or no disability (51.8%), and had received medical care for 3–12 months (67.1%). The mean number of outpatient visits per year and the results of the GEE Poisson regression, which demonstrated the relationship between on-site first aid and healthcare utilization, are presented in Table 2. The “no first aid” and “on-site first aid” group had visited outpatient clinics 15.243 and 13.928 times per year (4-year average), respectively. Participants who had received on-site first aid visited outpatient clinics 16.16% less frequently per year (aRR: 0.838, 95% CI = 0.740–0.950) than those who had not. Compared to the year after primary medical care termination (2018), the number of outpatient visits was significantly lower in the second year or later (2019–2021). The lower the disability grade, the lower the number of outpatient visits, especially for participants with no disability, who visited outpatient clinics 76.04% less often than those with disability grades 1–3 (aRR: 0.240; 95% CI = 0.172–0.334). Participants who received more than 3 months of primary medical care visited outpatient clinics more frequently than those who received less than 3 months of medical care. There was no significant difference in the total number and duration of hospitalizations per year between the participants who did and did not receive first aid (Supplementary Table 1).

Table 1

General characteristics of study participants as of year 2018
Variables		No first aid		On-site first aid
Variables		N	(%)	N	(%)
Total		1252	(100.0)	1840	(100.0)
Sex
	Male	1012	(80.8)	1550	(84.2)
	Female	240	(19.2)	290	(15.8)
Age
	Below 30s	209	(16.7)	313	(17.0)
	40s	238	(19.0)	395	(21.5)
	50s	447	(35.7)	648	(35.2)
	Above 60s	358	(28.6)	484	(26.3)
Education level
	High school graduation or lower	1007	(80.4)	1464	(79.6)
	University or higher	245	(19.6)	376	(20.4)
Current economic activity
	Employed	380	(30.4)	559	(30.4)
	Unemployed	85	(6.8)	111	(6.0)
	Economically inactive population	787	(62.9)	1170	(63.6)
Current household income
	Lowest quintile	127	(10.1)	146	(7.9)
	Second quintile	325	(26.0)	418	(22.7)
	Middle quintile	344	(27.5)	553	(30.1)
	Fourth quintile	301	(24.0)	465	(25.3)
	Top quintile	155	(12.4)	258	(14.0)
Area of residence
	Metropolitan	618	(49.4)	877	(47.7)
	Province(rural)	634	(50.6)	963	(52.3)
Past medical history before accident
	Without chronic disease	920	(73.5)	1414	(76.8)
	With chronic disease	332	(26.5)	426	(23.2)
Type of injury
	Fracture	777	(62.1)	1102	(59.9)
	Sprained	27	(2.2)	20	(1.1)
	Back pain/Musculoskeletal disease	27	(2.2)	19	(1.0)
	Amputation	90	(7.2)	232	(12.6)
	Cuts	6	(0.4)	18	(1.0)
	Bruising/Concussion	34	(2.7)	19	(1.0)
	Rupture/Laceration	204	(16.3)	310	(16.8)
	Burns	31	(2.5)	66	(3.6)
	Others	56	(4.5)	54	(3.9)
Disability grade
	Grade 1 ~ 3	20	(1.6)	48	(2.6)
	Grade 4 ~ 7	77	(6.2)	160	(8.7)
	Grade 8 ~ 9	125	(10.0)	218	(11.8)
	Grade 10 ~ 12	369	(29.5)	472	(25.7)
	Grade 13 ~ 14	383	(30.6)	583	(31.7)
	No disability	278	(22.2)	359	(19.5)
Period of primary medical care
	Less than 3 months	269	(21.5)	337	(18.3)
	3 ~ 12 months	840	(67.1)	1236	(67.2)
	More than 1 year	143	(11.4)	267	(14.5)

Table 2

The relationship between on-site first aid and the number of outpatient visits.
Variables		Mean (/year)	Total outpatient visits per year
			Model 1				Model 2				Model 3
			aRR	95% CI			aRR	95% CI			aRR	95% CI
On-site first aid
	No first aid	15.243	1.000				1.000				1.000
	On-site first aid	13.928	0.804*	0.702	-	0.920	0.840*	0.737	-	0.956	0.838*	0.740	-	0.950
Year
	2018		1.000				1.000				1.000
	2019		0.622*	0.554	-	0.698	0.582*	0.503	-	0.673	0.577*	0.503	-	0.662
	2020		0.580*	0.509	-	0.660	0.528*	0.455	-	0.613	0.527*	0.457	-	0.607
	2021		0.521*	0.466	-	0.583	0.464*	0.404	-	0.533	0.465*	0.409	-	0.529
Sex
	Male						1.000				1.000
	Female						1.072	0.917	-	1.252	1.149	0.977	-	1.352
Age
	Below 30s						1.000				1.000
	40s						1.227	0.946	-	1.593	1.104	0.853	-	1.429
	50s						1.364*	1.106	-	1.683	1.213	0.983	-	1.498
	Above 60s						2.010*	1.590	-	2.542	1.709*	1.351	-	2.162
Education level
	High school graduation or lower						1.000				1.000
	University or higher						0.828*	0.708	-	0.969	0.847*	0.727	-	0.988
Current economic activity
	Employed						1.000				1.000
	Unemployed						0.952	0.751	-	1.207	0.947	0.757	-	1.184
	Economically inactive population						0.931	0.816	-	1.062	0.925	0.819	-	1.045
Current household income
	Lowest quintile						1.000				1.000
	Second quintile						0.844*	0.715	-	0.997	0.843*	0.717	-	0.991
	Middle quintile						0.770*	0.657	-	0.903	0.752*	0.645	-	0.876
	Fourth quintile						0.954	0.787	-	1.157	0.889	0.736	-	1.074
	Top quintile						0.911	0.727	-	1.142	0.815	0.657	-	1.011
Area of residence
	Metropolitan						1.000				1.000
	Province(rural)						1.192*	1.048	-	1.356	1.151*	1.014	-	1.306
Past medical history before accident
	Without chronic disease						1.000				1.000
	With chronic disease						1.272*	1.093	-	1.479	1.295*	1.116	-	1.502
Type of injury
	Fracture										1.000
	Sprained										1.181	0.884	-	1.577
	Back pain/Musculoskeletal disease										1.313	0.839	-	2.054
	Amputation										0.629	0.531	-	0.744
	Cuts										0.804	0.457	-	1.413
	Bruising/Concussion										1.191	0.709	-	2.001
	Rupture/Laceration										0.932	0.794	-	1.094
	Burns										0.793	0.510	-	1.232
	Others										0.860	0.676	-	1.094
Disability grade
	Grade 1 ~ 3										1.000
	Grade 4 ~ 7										0.400*	0.299	-	0.535
	Grade 8 ~ 9										0.379*	0.277	-	0.518
	Grade 10 ~ 12										0.336*	0.243	-	0.464
	Grade 13 ~ 14										0.236*	0.171	-	0.326
	No disability										0.240*	0.172	-	0.334
Period of primary medical care
	Less than 3 months										1.000
	3 ~ 12 months										1.285*	1.047	-	1.577
	More than 1 year										1.661*	1.281	-	2.154
* Statistically significant; aRR = adjusted Relative Risk; CI = Confidence Interval.

The subgroup analyses based on covariates are presented in Table 3. The following subgroups showed significantly fewer outpatient visits per year for participants who received first aid compared to those who did not: in 2021 (4 years after primary medical care termination); males above 50 years of age; with a high school education or lower; currently employed; living in provinces; with a rupture/laceration and other types of injury; without disabilities; and had received less than 12 months of primary medical care.

Table 3

Subgroup analysis based on the general characteristics of participants: total number of outpatients visit.
Variables		Total outpatients visit per year
		No first aid	On-site first aid
		aRR	aRR	95% CI
Year
	2018	1.000	0.900	0.777	-	1.043
	2019	1.000	0.827	0.682	-	1.002
	2020	1.000	0.844	0.663	-	1.073
	2021	1.000	0.717*	0.597	-	0.861
Sex
	Male	1.000	0.822*	0.713	-	0.948
	Female	1.000	0.904	0.718	-	1.139
Age
	Below 30s	1.000	1.103	0.818	-	1.488
	40s	1.000	0.977	0.721	-	1.326
	50s	1.000	0.768*	0.636	-	0.926
	Above 60s	1.000	0.799*	0.654	-	0.976
Education level
	High school graduation or lower	1.000	0.825*	0.715	-	0.951
	University or higher	1.000	0.865	0.672	-	1.114
Economic activity
	Employed	1.000	0.811*	0.685	-	0.960
	Unemployed	1.000	0.916	0.685		1.226
	Economically inactive population	1.000	0.891	0.762	-	1.040
Economic status
	Lowest quintile	1.000	0.904	0.663	-	1.234
	Second quintile	1.000	0.778*	0.642	-	0.942
	Middle quintile	1.000	0.897	0.778	-	1.035
	Fourth quintile	1.000	0.721*	0.571	-	0.909
	Top quintile	1.000	0.747	0.536		1.041
Area of residence
	Metropolitan	1.000	0.936	0.797	-	1.099
	Province(rural)	1.000	0.791*	0.659	-	0.948
Past medical history before accident
	Without chronic disease	1.000	0.868	0.740	-	1.017
	With chronic disease	1.000	0.842	0.696	-	1.018
Type of injury
	Fracture	1.000	0.863	0.729	-	1.022
	Sprained	1.000	0.829	0.552	-	1.246
	Back pain/Musculoskeletal disease	1.000	0.396	0.138	-	1.137
	Amputation	1.000	0.947	0.718	-	1.250
	Cuts	1.000	0.779	0.301	-	2.013
	Bruising/Concussion	1.000	0.401	0.155	-	1.034
	Rupture/Laceration	1.000	0.749*	0.582	-	0.965
	Burns	1.000	1.133	0.747	-	1.718
	Others	1.000	0.903	0.638	-	1.279
Disability grade
	Grade 1 ~ 3	1.000	N.A^a
	Grade 4 ~ 7	1.000	0.946	0.715	-	1.250
	Grade 8 ~ 9	1.000	1.129	0.830	-	1.536
	Grade 10 ~ 12	1.000	0.936	0.776	-	1.129
	Grade 13 ~ 14	1.000	0.849	0.702	-	1.027
	No disability	1.000	0.787*	0.643	-	0.962
Period of primary medical care
	Less than 3 months	1.000	0.775*	0.614	-	0.979
	3 ~ 12 months	1.000	0.844*	0.719	-	0.990
	More than 1 year	1.000	1.311	0.992	-	1.731
a Due to insufficient number of samples.
* Statistically significant; aRR = adjusted Relative Risk; CI = Confidence Interval; N.A = Not Applicable

The detailed effects of on-site first aid based on the transfer time to the emergency room are presented in Fig. 1. Compared to participants who did not receive first aid, those who did with a transfer time of less than 0.5 hour to the emergency room visited outpatient clinics 14.87% less frequently per year (aRR: 0.851, 95% CI = 0.750–0.966).

This study examined the percentage of on-site first aid for industrial accidents among Korean workers from 2018 to 2021, and its effect on the rate of their healthcare utilization during a 4-year period after the termination of primary medical care. The study also considered the transfer time to the emergency room.

After the termination of primary medical care for industrial accidents, IIW who did not receive on-site first aid visited outpatient clinics 15.243 times per year. Among the IIW, 59.5% received on-site first aid and, on average, visited outpatient clinics 13.928 times per year after primary care termination, which was 16.16% less than those who did not receive first aid (Table 2). When the transfer time to the emergency room was more than 30 minutes, there was no significant difference in the outpatient visit rate between IIW who received first aid and those who did not (Fig. 1). However, there were no significant differences in the total hospitalization count or duration. Additionally, a decrease in the frequency of outpatient use was observed in subgroups of men over 50 years old living in provinces, indicating poorer medical surroundings compared to metropolitan areas and poorer health conditions relative to young patients. Moreover, first aid significantly reduced the number of outpatient visits in minor industrial accidents (mild disability level and short primary medical care period) compared with severe accidents. On-site first aid for ruptures/lacerations was associated with fewer outpatient visits than that for other types of injuries (Supplementary Table 1).

We adjusted the analyses for previously investigated factors associated with healthcare utilization, including income level, insurance coverage, chronic diseases, advanced age, and being female [13–16]. Additionally, we adjusted for the type of injury and consequences of accidents. Appropriate on-site first aid is crucial for reducing healthcare utilization; therefore, employees should receive first-aid training. As stated in the Introduction, on-site first aid may lead to a better prognosis for industrial accidents and reduced healthcare utilization. Furthermore, having numerous workers who are capable of administering first aid can enhance preparedness for industrial accidents. However, we did not observe a significant difference in hospitalization rates, indicating that hospital treatment is likely to be completed during primary medical care for industrial accidents.

This study had several limitations. First, some variables, including on-site first aid and healthcare utilization, were self-reported, which may have led to low data accuracy. Moreover, owing to data unavailability, the study did not include detailed information on on-site first aid, such as the first-aid provider, industrial accidents, and medical interventions during first aid. The reasons for healthcare utilization were also not considered. Furthermore, this study did not analyze the severity of industrial accidents nor the acute medical conditions that occurred immediately after. Our results cannot be applied to other trauma events such as car accidents and cannot be generalized to other countries with different surroundings for industrial accidents.

Despite its limitations, our study provides valuable insights into the potential benefits of on-site first aid in reducing healthcare utilization for industrial accidents. Specifically, the study found that first aid for ruptures/lacerations and minor accidents, with less than 30 minutes of transfer time to the emergency room, could reduce outpatient visits. Timely first-aid provision and employee education are necessary to reduce outpatient utilization rates.

IIW

Industrially injured workers

KRW

South Korean Won

PSWCI

Panel Study of Workers’ Compensation Insurance

KCOMWEL

Korea Workers’ Compensation & Welfare Service

TAPI

Tablet-assisted personal interviews

KOSHA

Korea Occupational Safety and Health Agency

GEE

Generalized estimating equation

QIC

Quasi-likelihood under Independence Model Criterion

aRR

Adjusted relative risk

CI

Confidence intervals

VIF

Variance inflation factors

Ethics approval and consent to participate

All the procedures were performed in accordance with the relevant guidelines and regulations of the Declaration of Helsinki. Additional ethics approval and informed consent was waived due to publicly available and deidentified data based on the local legislation and institutional requirements (approved from the Commissioner of the Statistics Korea, national statistics approval number: 439001).

Consent for publication

Not applicable

Availability of data and materials

The data analyzed in this study were obtained from the Panel Study of Workers’ Compensation Insurance (PSWCI), which is publicly available. All data were obtained from an official website (https://www.comwel.or.kr/Researchinstitute/index.do).

Competing interests

On behalf of all the authors, the corresponding author states that there are no conflicts of interest.

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2022R1F1A1062794). Any opinions, findings, conclusions, or recommendations expressed here are those of the authors alone.

Authors’ Contribution

SIJ: conceived, designed, directed the study, critically revied the manuscript, and had primary responsibility for final content. JK: conceptualized the study, conducted statistical analysis, interpreted the data, wrote the initial draft of the manuscript, and revised the manuscript. HK and ECP conducted the statistical analyses of the data and critically reviewed. SIJ: responsible for the revision of the manuscript. All authors: participated sufficiently in the work, read and approved the final manuscript.

Acknowledgements

We would like to thank the staff of the Institute of Health Services Research, Yonsei University, for their insightful comments and Editage (www.editage.co.kr) for providing English language editing assistance. We thank the Korea Workers’ Compensation & Welfare Service (Labour Welfare Research Institute) for offering raw data on PSWCI (Panel Study of Workers’ Compensation Insurance). The contents of the paper are solely the responsibility of the author and do not represent the official views of the Labour Welfare Research Institute.

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No competing interests reported.

SupplementaryTable1.docx

Effect of on-site first aid for industrial accidents on healthcare utilization after primary medical care: A 4-year longitudinal study

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Abstract

Figures

Background

Methods

Study population and data

Measures

Covariates

Statistical analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1