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* From the Department of Pulmonary, Allergy, and Critical Care Medicine (Dr. Shofer), Duke University School of Medicine; Pulmonary Section (Dr. Kuschner), Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; and Division of Pulmonary and Critical Care (Dr. Haus), Stanford University School of Medicine, Stanford, CA.
Correspondence to: Ware Kuschner, MD, FCCP, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave, Pulmonary Section, Mail Stop 111 P, Palo Alto, CA 94304; e-mail: ware.kuschnermd{at}va.gov
Abstract
Background: Approximately 10 to 15% of new-onset asthma in adults is attributable to occupational exposure. The occupational history is the most important instrument in the diagnosis of occupational asthma (OA).
Study objectives: To assess the quality of occupational histories obtained by health-care providers and to measure the prevalence of clinician-diagnosed OA in a population at elevated risk for OA.
Setting: An academic US Department of Veteran Affairs medical center.
Study population: One hundred ninety-seven adults (age range, 18 to 55 years) with newly diagnosed asthma who had completed pulmonary function testing (PFT) and a structured respiratory health questionnaire.
Measurements: We conducted a structured retrospective comparison of occupational respiratory health history documented by clinicians with data documented by patients on a structured questionnaire. We analyzed PFT results to assess physiologic impairment. We also conducted a structured examination of the actions taken by health-care providers based on their occupational history assessments.
Results: Patient self-reports of respiratory exposures and symptoms were common. A job title was documented by one or more clinicians in 75% of patient medical records. Additional occupational history data were charted much less frequently. A diagnosis of OA was made in only 2% of patients. Clinical action to address OA was documented for only one patient.
Conclusions: Clinicians who manage adults with newly diagnosed asthma take incomplete occupational histories. We detected discordance between the occupational exposure histories documented by patients and those charted by clinicians. OA may go unrecognized and possibly undermanaged by clinicians.
Key Words: asthma • occupational exposure • occupational medicine • workplace
Occupational diseases are prevalent and costly.12 A total of 5,707,200 cases of occupational injury and illness were reported in the United States in 1999, an incidence of 41 per 10,000 workers employed full time by private industry.3 While injuries account for most occupational disorders, the incidence of illness attributable to work in the United States is substantial. An estimated 350,000 to 862,200 new cases of occupational illness occur annually.24 In 1992, occupational illness and injuries combined were estimated to have cost the US health-care system $65 billion in direct costs and $106 billion in indirect costs. Occupational illnesses alone resulted in costs of $25.5 billion ($16 billion direct and $9.5 billion indirect).4
The prevalence of hazardous occupational exposures among patients receiving medical care in general medicine clinics has been reported to be 39 to 75%.56 Although histories of hazardous exposure are common among workers seeking medical care, most occupational illnesses go undetected due to inadequate screening of workers and failure of health-care practitioners to recognize associations between occupational exposures and subsequent disease states.1257
Failure to recognize occupational illness represents a missed opportunity to make important health-care interventions at both the patient and, possibly, the population level. A diagnosis of an occupational illness should result in counseling of the worker against continued exposure to the relevant hazard(s) either through modification of job duties, product substitution, use of personal protective devices, or a change of job. Additionally, employer notification may result in improvements in workplace engineering controls in order to prevent illness among other employees. Finally, determination that an illness has an occupational etiology may qualify the affected worker for financial compensation.1
Occupational asthma (OA) is the most common occupational respiratory illness in industrialized nations.8 Ten to 15% of all new-onset adult asthma is attributable to occupational substance exposure.9101112 More than 250 compounds encountered in a variety of workplaces are known to cause asthma, and many agents, including gases, dusts, and fumes, aggravate existing asthma.813 Accordingly, a thorough occupational history with appropriate follow-up action is indicated in any adult with asthma, especially among workers with newly diagnosed or worsening asthma.
The best instrument for detecting occupational illness is the occupational history.121114 However, occupational histories obtained by health-care providers may be incomplete and therefore lack adequate sensitivity for identifying OA.7
In order to assess the quality of occupational histories collected by health-care providers in our health-care system, we conducted a structured retrospective analysis of working age adults with newly diagnosed asthma. We tested the following hypotheses: (1) health-care providers routinely fail to identify and document potentially significant occupational exposures in adults with newly diagnosed asthma; and (2) when potentially toxic occupational exposures are recognized, health-care providers fail to take action utilizing this information.
Materials and Methods
Overview
We conducted a structured analysis of the medical records of working age adults with newly diagnosed asthma in order to assess the content and quality of occupational histories documented by health-care providers. We compared occupational histories documented by health-care providers with health and occupational exposure information documented by the study patients on a structured self-administered questionnaire completed at the time of clinician-ordered pulmonary function testing (PFT). We analyzed PFT results to assess physiologic impairment. We also conducted a structured examination of the actions taken by health-care providers based on their occupational history assessments. The study was approved by the Stanford University Administrative Panel on Human Subjects in Medical Research and the Veterans Affairs Palo Alto Health Care System Research and Development Committee.
Study Setting
The study was conducted at the US Department of Veterans Affairs Palo Alto Health Care System (VAPAHCS). VAPAHCS operates three hospital-based divisions with a total of 913 beds and six community-based outpatient clinics delivering health care to veterans of the US military services. The average daily patient census is 723. In fiscal year 2001, there were 63,683 enrolled veterans and 590,000 outpatient visits throughout the health-care system.15 VAPAHCS operated three pulmonary function laboratories during the study period.
VAPAHCS Medical Record System
All health-care provider notes (inpatient and outpatient notes and hospital discharge summaries) and virtually all other elements of patient medical records, including all test results, physician orders, medication lists, and the International Classification of Diseases, Ninth Revision, Clinical Modification codes, are stored in electronic format in the VAPAHCS computer network. Pulmonary function laboratory questionnaires completed by patients are among the few documents that are not stored electronically. These are stored as paper files (other documents stored as paper files are signed consent forms, advance health-care directives, and intraoperative anesthesia reports). We analyzed three sources of data: (1) health-care provider notes from the electronic medical records; (2) PFT results; and (3) pulmonary function laboratory questionnaire responses.
VAPAHCS Pulmonary Function Laboratory Questionnaire
As part of routine clinical care, patients referred to any of the three VAPAHCS pulmonary function laboratories for testing are directed to complete a structured self-administered questionnaire that ascertains information about pulmonary health. The PFT questionnaire includes domains on past and current pulmonary history, respiratory symptoms (cough and dyspnea), bronchodilator medication usage, smoking history, and occupational exposures. PFT questionnaire domains are presented in Table 1
. The purpose of the questionnaire is to facilitate performance of pulmonary function testing by laboratory technicians and interpretation of the PFT by staff pulmonologists. The completed PFT questionnaires are maintained in the files of the pulmonary function laboratories, are not part of the electronic medical records, and are not typically reviewed by referring clinicians or other VAPAHCS health-care practitioners. The patients’ responses to the questionnaire are not included in the PFT study interpretations that are entered into the electronic medical records. Therefore, referring clinicians are effectively, although not formally, blinded to the responses their patients provide on the PFT laboratory questionnaire.
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Two investigators (S.S. and B.H.) abstracted individual patient medical records for the time period 1 year prior to and 1 year following the date of entry of the ICD-9 CM asthma diagnosis into the medical record. Therefore, the medical records spanning 2 years were reviewed for each patient. All medical record notes were reviewed with the exception of those titled "mental health," "dental," "optometry/ophthalmology," "outpatient nursing," and "pharmacy new prescription." We searched electronic medical records for documentation of occupational history, either formally subtitled as such, or embedded in any part of the progress notes. The specific occupational history elements targeted in the review were as follows: (1) designation of employment status (ie, employed, unemployed, or disabled); and, if employed, (2) job title, (3) specific occupational duties, (4) types of exposures present at work, (5) types of protective equipment used at work, and (6) prior occupational exposure history. A least-restrictive review strategy was employed by including any notation within the medical record relating to an occupational history element, irrespective of completeness, as a positive response. In addition, records in which there was documentation of a negative respiratory exposure history (ie, specific documentation that there were no relevant occupational exposure) were tallied as having charted the occupational history element "exposure at work." Our record review also included a search for documentation of any of the following: (1) a formal clinician diagnosis of OA or work-related asthma, (2) indication of the possibility of a diagnosis of OA or work-related asthma, and (3) indication of the possibility of an occupational factor contributing to asthma.
Among patients in whom a health-care provider documented that an occupational factor was associated with the asthma, the medical record was reviewed to determine whether further action was pursued based on this assessment. We reviewed those charts specifically for documentation of the following: (1) request made by the health-care provider of the patient to gain additional descriptive information about one or more potentially relevant exposures (eg, a request for material safety data sheets), or documentation by the health-care provider of his/her intention to contact the employer directly in order to obtain more information; (2) referral to subspecialty care (eg, pulmonary medicine or occupational medicine) with the specific intention of having the patient evaluated for OA or work-related asthma; (3) request for after work shift or cross work shift spirometry or peak expiratory airflow monitoring with or without maintenance of diary of symptoms and exposures; (4) counseling the patient about exposure avoidance, including the role of personal respiratory protection and the possible positive health consequences of a job change or change in job duties; (5) referral of patient to an occupational claims board; (6) referral of patient for legal counsel to pursue financial compensation; and (7) filing of a California State Doctors First Report of Injury. The Doctors First Report of Injury is a California state-mandated reporting program whereby all work-related injuries or illness treated by a physician are reported within 5 days of provision of care to the insurance administrator of the patient’s employer. These forms are then forwarded to the California Department of Industrial Relations.16 The occupational history elements and health-care provider interventions targeted in the chart review were decided on in an a priori manner (ie, prior to initiation of the medical record review) by the three investigators (S.S., B.H., and W.G.K.).
Occupational Risk Stratification
Patients were risk stratified into high-risk and low-risk occupations for OA as previously described by Johnson et al.11
Authors (Health-Care Providers) of Medical Record Notes
We identified the professional specialties and titles of the authors (health-care providers) of medical record notes.
PFT Data
We collected the following PFT data from the medical records: (1) FEV1; (2) FEV1/FVC ratio; and (3) the presence of a bronchodilator response as defined by a postbronchodilator increase in FEV1 of at least 12% and 200 mL 15 min following inhalation of albuterol, 180 µg (two puffs), via metered-dose inhaler.
Statistical Analysis
Data were entered into database (Microsoft Access 2000; Microsoft; Redmond, WA). Spreadsheet data were imported (Statistica; StatSoft; Tulsa, OK) and were used to calculate mean values and SDs.
Results
The computerized database query identified 893 patients with a diagnosis of asthma newly entered into their electronic medical records during the patient identification period. Of these, 334 patients had completed PFT at VAPAHCS. Of these, 197 patients had also completed a pulmonary function laboratory questionnaire that was recovered from the archives of one of the three VAPAHCS pulmonary function laboratories. This group of 197 patients comprised the study group.
Patient Characteristics and Pulmonary Physiology
Table 2
shows the demographic characteristics, smoking status, and pulmonary function characteristics of the study group (n = 197). Consistent with a military veteran population, most patients were men: 161 patients (82%). The mean (± SD) age was 46 ± 8 years, 55 patients (28%) were current smokers, 55 patients (28%) had a positive bronchodilator response at the time of PFT, and 163 patients (83%) reported use of bronchodilators as part of their medication regimen.
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Other than job title, occupational history was infrequently documented by health-care providers (Table 3 ). Documentation of inquiries into the presence of potentially significant respiratory exposures at work, including negative histories (ie, specific documentation that there were no relevant exposures), were present in at least one note in the records of 21 patients (11%). Descriptions of specific work duties were identified in nine patients (5%).
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Characteristics of Health-Care Providers
A total of 659 health-care providers were identified as authors of the 3,096 reviewed notes (Table 4
). Sixty-four percent of the authors were physicians spanning a broad range of medical and surgical subspecialties. The other authors were health-care providers in allied fields.
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We conducted a structured review of the medical records of working-age patients with newly diagnosed asthma in order to assess the quality of clinician-ascertained occupational histories in a patient population at risk for OA. We searched the medical notes written by a large group of physician and nonphysician health-care providers for specific occupational history elements and for documentation of specific actions taken by their health-care providers. We also assessed the prevalence of respiratory symptoms and occupational exposures as documented on a patient self-administered questionnaire. We found discordance between the occupational history information documented on patient questionnaires—which indicated that most had histories of occupational exposures meriting further exploration and potentially health-care provider interventions—and the limited occupational histories and actions taken by health-care providers.
Our study population may have been at significant risk for OA. More than one half of the study population reported occupational exposure to respirable agents. Most complained of cough and dyspnea. Bronchodilator responses on PFT were common, consistent with incompletely controlled asthma. The significance of the patients’ self-reported respiratory exposures is unknown, but they were largely not addressed by health-care providers. Only four patients (2%) received a diagnosis of OA, and other work-related asthma was not diagnosed. This proportion of adult-onset asthma is markedly less than the 10 to 15% attributable to work elsewhere.9101112 Only one patient had action taken by a health-care provider to address OA.
Health-care providers documented a job title, or nonemployment status, in 75% of patients. Approximately one fourth of these patients were in occupations with an increased prevalence of OA. However, beyond job status, occupational history was infrequently collected. An appropriate occupational history includes a description of worker duties, types of current and past exposures at work, presence of symptoms at work and, if relevant, the type of protective equipment used at work. A job title alone does not constitute an adequate occupational history and is insufficient to make a diagnosis of OA.1317 If OA is suspected, further information should be collected by the health-care provider about the specific types of exposures present at work, the presence of symptoms in coworkers, and consideration should be given to contacting the work supervisor about work-related illnesses at the job site.111718
There are few prior reports that have assessed the quality of occupational histories among patients at risk of occupational illness. McCahy et al19 compared hospital admission records with structured interviews for the assessment of occupational risk factors in patients with bladder cancer. They found an accurate job title recorded in only 39% of 108 reviewed cases. In a study20 of occupational history in asthmatics enrolled in a health maintenance organization, only 15% of patients had occupationally related symptoms recorded in general practitioner notes. Sama et al21 performed a longitudinal analysis of adult-onset asthma incidence among health maintenance organization members and found job titles present in 22% of medical records and documentation of work-related exposures in 7%. These authors concluded that clinicians tend to ignore the contribution of occupational and environmental exposures in the evaluation of adult-onset asthma.
It is possible some health-care providers believed their patients had COPD instead of asthma and, as a consequence, did not consider a possible link between work and respiratory disorders. Approximately one fourth of patients in this investigation were smokers, and many had obstructive airflow physiology, while most did not manifest a bronchodilator response at the time of PFT. However, while demonstration of bronchodilator response is essentially diagnostic of asthma, its absence at one time point does not exclude the diagnosis.22 Furthermore, a long-term longitudinal investigation23 of asthmatic patients showed a similar point prevalence of a positive bronchodilator response on PFT. Additionally, other reports2425 examining occupational exposures in smokers with COPD suggest as much as 15 to 20% of COPD may be attributable to occupational exposures. These results suggest that occupational history collection is important in detecting occupationally acquired COPD as well as asthma. Accordingly, a complete respiratory occupational history is warranted for essentially all adults with obstructive lung disease, irrespective of smoking history or bronchodilator response status.
Education regarding the importance of occupational history collection may be beneficial in elevating providers’ awareness of these diseases. In our assessment of patients with a more complete occupational history, the majority of these histories were obtained by staff physicians in pulmonary or general medical clinics, suggesting that additional training may improve health-care providers’ ability to collect an adequate occupational history. In a survey of American College of Chest Physicians members regarding the frequency of encountering patients with occupational or environmental lung diseases, Harber et al26 found that 99% of responding members would like additional education regarding these diseases. Interestingly, many of the additional occupational history elements were collected in surgical subspecialty clinics, again suggesting that willingness to collect these histories is present in nonmedical-based specialties, but an educational deficit may impede the collection of these histories on a more regular basis.
The primary limitation of this study was the inability to determine the actual prevalence of OA in the study population. We employed a standard screening questionnaire that was not designed to diagnose OA. Our questionnaire did reveal that 62% of patients had a history of occupational exposure to gas, dust, or fumes, similar to results from a prior survey5 specifically designed to detect history of occupational exposure in a veteran population.
We cannot exclude the possibility that additional occupational history may have been recorded at a visit outside of the 2-year chart review time frame. Even if this had occurred, documentation of occupational history would still be advisable at the time of a new diagnosis of asthma, in order to address the possibility of an occupational factor.
We cannot exclude the possibility that some cases of asthma, though newly identified, had been longstanding. However, this possibility does not exclude the potential usefulness of a complete occupational history at the time of recognition.
Our findings are not necessarily generalizable to other health-care settings. However, previous studies examining the quality of care at multiple health-care facilities within the Veterans Affairs Health Care System (VA) compared with Medicare database27 and a national sample from 12 community-based sites28 found favorable quality metrics associated with the care delivered in VA hospitals. This would suggest that VA health-care provider’s practice quality is equal to, or superior to that of community-based health-care providers. Other studies29303132 also suggest that the VA is at least as effective as non-VA health-care systems in delivering preventive health-care services. Accordingly, we speculate that occupational histories are deficient in most clinical practice environments where asthma is being diagnosed and managed.
In conclusion, in this population of working-age adults with newly diagnosed asthma, patient self-reports of occupational respirable exposures and respiratory symptoms were common. Health-care providers infrequently documented details about job duties, workplace exposures, and other essential elements of the occupational history. Fewer than expected cases of OA were diagnosed by health-care providers based on estimates from published reports. A significant burden of OA may go unrecognized by clinicians.
Footnotes
Abbreviations: OA = occupational asthma; PFT = pulmonary function testing; VA = Veterans Affairs Health Care System; VAPAHCS = US Department of Veterans Affairs Palo Alto Health Care System
This work was performed at the Veterans Affairs Palo Alto Health Care System. The views and opinions of the authors do not necessarily reflect those of the Veteran Affairs Palo Alto Health Care System or of the United States Department of Veterans Affairs.
Presented at the American Thoracic Society International Conference, Seattle, WA, May 19, 2003.
The authors have no conflict of interest or financial interest in the subject matter.
Received for publication October 17, 2005. Accepted for publication January 26, 2006.
References
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