Physician-patient communication regarding asthma and work

Clinical Decision Support for Worker Health: A Five-Site Qualitative Needs Assessment in Primary Care Settings

BACKGROUND

Although patients who work and have related health issues are usually first seen in primary care, providers in these settings do not routinely ask questions about work. Guidelines to help manage such patients are rarely used in primary care. Electronic health record (EHR) systems with worker health clinical decision support (CDS) tools have potential for assisting these practices.

OBJECTIVE

This study aimed to identify the need for, and barriers and facilitators related to, implementation of CDS tools for the clinical management of working patients in a variety of primary care settings.

METHODS

We used a qualitative design that included analysis of interview transcripts and observational field notes from 10 clinics in five organizations.

RESULTS

We interviewed 83 providers, staff members, managers, informatics and information technology experts, and leaders and spent 35 hours observing. We identified eight themes in four categories related to CDS for worker health (operational issues, usefulness of proposed CDS, effort and time-related issues, and topic-specific issues). These categories were classified as facilitators or barriers to the use of the CDS tools. Facilitators related to operational issues include current technical feasibility and new work patterns associated with the coordinated care model. Facilitators concerning usefulness include users' need for awareness and evidence-based tools, appropriateness of the proposed CDS for their patients, and the benefits of population health data. Barriers that are effort-related include additional time this proposed CDS might take, and other pressing organizational priorities. Barriers that are topic-specific include sensitive issues related to health and work and the complexities of information about work.

CONCLUSION

We discovered several themes not previously described that can guide future CDS development: technical feasibility of the proposed CDS within commercial EHRs, the sensitive nature of some CDS content, and the need to assist the entire health care team in managing worker health.

Improving detection of work-related asthma: a review of gaps in awareness, reporting and knowledge translation

Background

Work-related asthma (WRA) accounts for up to 25% of all adults with asthma. Early diagnosis is key for optimal management as delays in diagnosis are associated with worse outcomes. However, WRA is significantly underreported and the median time to diagnosis is 4 years. The objective of this review is to identify the gaps in awareness and reporting of WRA and identify gaps in current knowledge translation strategies for chronic disease in general, and asthma specifically. This will identify reasons for delays in WRA diagnosis, as well inform suggestions to improve knowledge translation strategies for dissemination and implementation of WRA prevention and management guidelines.

Methods

Non-systematic literature reviews were conducted on PubMed with a focus on work-related asthma screening and diagnosis, and knowledge translation or translational medicine research in asthma and chronic disease. In total, 3571 titles and abstracts were reviewed with no restriction on date published. Of those, 207 were relevant and fully read. Another 37 articles were included and reviewed after citation reviews of articles from the initial search and from suggestions from editors. In total, 63 articles were included in the final review.

Results

Patients, employers, and healthcare professionals lack awareness and under-report WRA which contribute to the delayed diagnosis of WRA, primarily through lack of education, stigma associated with WRA, and lack of awareness and screening in primary care. Knowledge translation strategies for asthma research typically involve the creation of guidelines for diagnosis of the disease, asthma care plans and tools for education and management. While there are some prevention programs in place for certain industries, gaps in knowledge translation strategies including lack of screening tools currently available for WRA, poor education of employers and physicians in identifying WRA, and education of patients is often done post-diagnosis and focuses on management rather than prevention or screening.

Conclusion

Future knowledge translation strategies should focus on educating employees and employers well before potential exposure to agents associated with WRA and screening for WRA in primary care to enable health care providers to recognize and diagnose WRA.

Asthma medication use among adults with current asthma by work-related asthma status, Asthma Call-back Survey, 29 states, 2012-2013

OBJECTIVE

Asthma severity is defined as the intensity of treatment required to achieve good control of asthma symptoms. Studies have shown that work-related asthma (WRA) can be associated with poorer asthma control and more severe symptoms than non-WRA. Associations between asthma medications and WRA status were assessed using data from the 2012-2013 Asthma Call-back Survey among ever-employed adults (≥18 years) with current asthma from 29 states.

METHODS

Persons with WRA had been told by a physician that their asthma was work-related. Persons with possible WRA had asthma caused or made worse by their current or previous job, but did not have physician-diagnosed WRA. Asthma medications were classified as controller (i.e., long-acting β-agonist, inhaled corticosteroid, oral corticosteroid, cromolyn/nedocromil, leukotriene pathway inhibitor, methylxanthine, anti-cholinergics) and rescue (i.e., short-acting β-agonist). Demographic and clinical characteristics were examined. Associations between asthma medications and WRA status were assessed using a multivariate logistic regression to calculate adjusted prevalence ratios (PRs).

RESULTS

Among an estimated 15 million ever-employed adults with current asthma, 14.7% had WRA and an additional 40.4% had possible WRA. Compared with adults with non-WRA, those with WRA were more likely to have taken anti-cholinergics (PR = 1.80), leukotriene pathway inhibitor (PR = 1.59), and methylxanthine (PR = 4.76), and those with possible WRA were more likely to have taken methylxanthine (PR = 2.85).

CONCLUSIONS

Results provide additional evidence of a higher proportion of severe asthma among adults with WRA compared to non-WRA. To achieve optimal asthma control, adults with WRA may require additional intervention, such as environmental controls or removal from the workplace exposure.

Respirator Use Among US Farm Operators With Asthma: Results From the 2011 Farm and Ranch Safety Survey

OBJECTIVE

The purpose of this study was to estimate the national prevalence of respirator use among farm operators with farm work-related asthma and factors associated with respirator use.

METHODS

The authors examined the 2011 Farm and Ranch Safety Survey, a national survey collected from 11,210 actively farming farm operators in the United States. Adjusted prevalence ratios (aPORs) of respirator use were calculated by demographic characteristics, farm characteristics, asthma characteristics, and selected exposures and hazards.

RESULTS

Among the estimated 2.2 million farm operators in 2011, 35.7% reported using a respirator in the past 12 months. Respirator use was significantly (P < .05) associated with age, marital status, sex, smoking status, farm value of sales, farm type, farm acreage, and geographic region. Operators who work with pesticides were 3.5 times more likely to use respirator than those who did not work with pesticides (P < .0001). Among those with current asthma, 60.8% of operators with farm work-related asthma used respirators compared with 44.4% of operators with non-farm work-related asthma (P = .03). Farm operators with farm work-related asthma who had an asthma attack at work were 11.3 times more likely to report respirator use than those who did not have an asthma attack at work (P = .03).

CONCLUSIONS

Personal protective equipment, including respirators, is an approach to reducing respiratory exposures in agricultural settings, in particular among those with farm work-related asthma. Education for respirator use and evaluation for respirator tolerance should be considered.

Assessing work-asthma interaction with Amazon Mechanical Turk

OBJECTIVES

To illustrate the utility of crowdsourcing for occupational health surveillance.

METHODS

Amazon Mechanical Turk was used to recruit and obtain information from employed persons with asthma, who answered questions about work-asthma interactions.

RESULTS

Data collection from 60 subjects required only a few hours. Participants spent on average 7 minutes responding to seven questions (one optional) and used an average of 708 words. Work exacerbation, interference of asthma with work, and suggested workplace accommodation are frequent (83% reported at least one interaction).

CONCLUSIONS

The full spectrum of work-asthma interactions should be considered. Modern crowdsourcing methods have considerable potential as occupational health surveillance tools because of their effectiveness; efficiency and financial viability are additional important advantages.

Isocyanates and work-related asthma: Findings from California, Massachusetts, Michigan, and New Jersey, 1993-2008

BACKGROUND

Isocyanates remain a leading cause of work-related asthma (WRA).

METHODS

Two independent data systems were analyzed for the period 1993-2008: (1) State-based WRA case surveillance data on persons with isocyanate-induced WRA from four states, and (2) Occupational Safety and Health Administration (OSHA) Integrated Management Information System (IMIS) isocyanate air sampling results.

RESULTS

We identified 368 cases of isocyanate-induced WRA from 32 industries and 678 OSHA isocyanate air samples with detectable levels from 31 industries. Seventeen industries were unique to one or the other dataset.

CONCLUSION

Isocyanate-induced WRA continues to occur in a wide variety of industries. Two data systems uncovered industries with isocyanate exposures and/or illness. Improved control measures and standards, including medical surveillance, are needed. More emphasis is needed on task-specific guidance, spill clean-up procedures, skin and respiratory protection, and targeted medical monitoring to mitigate the hazards of isocyanate use.

Patient-physician communication about work-related asthma: what we do and do not know

BACKGROUND

Effective patient-physician communication is the key component of the patient-physician relationship.

OBJECTIVE

To assess the proportion of ever-employed adults with current asthma who talked about asthma associated with work with their physician or other health professional and to identify factors associated with this communication.

METHODS

The 2006 to 2010 Behavioral Risk Factor Surveillance System Asthma Call-Back Survey data from 40 states and the District of Columbia for ever-employed adults (≥18 years old) with current asthma (N = 50,433) were examined. Multivariable logistic regression analyses were conducted to identify factors associated with communication with a health professional about asthma and work.

RESULTS

Among ever-employed adults with current asthma, 9.1% were ever told by a physician that their asthma was related to any job they ever had and 11.7% ever told a physician or other health professional that this was the case. When responses to the 2 questions were combined, the proportion of those who communicated with a health professional about asthma and work was 14.7%. Communication with a health professional about asthma and work was associated with age, race or ethnicity, employment, education, income, insurance, and urgent treatment for worsening asthma.

CONCLUSION

A small proportion of patients with asthma might communicate with a health professional about asthma associated with work. Future studies should examine whether patients with asthma ever discussed with a health professional the possibility that their asthma might be related to work to provide information on the frequency of patient-clinician communication about asthma related to work.

Farm work-related asthma among US primary farm operators

The objective of this study was to estimate the prevalence of current asthma and the proportion of current asthma that is related to work on the farm among primary farm operators. The 2011 Farm and Ranch Safety Survey data were used to produce estimates and prevalence odds ratios. An estimated 5.1% of farm operators had asthma. Of these, 15.4% had farm work-related asthma. Among operators with farm work-related asthma, 54.8% (95% confidence interval [CI]: 41.8%-68.2%) had an asthma attack in the prior 12 months and 33.3% (95% CI: 21.2%-45.4%) had an asthma attack that occurred while doing farm work. Of those who had an asthma attack that occurred while doing farm work, 65.0% associated their asthma attack with plant/tree materials. This study provides updated information on asthma and the proportion of current asthma that is related to work on the farm and identifies certain groups of farm operators that might benefit from workplace asthma prevention intervention.

Employed adults with asthma who have frequent workplace exposures

Abstract Objective: The recent increase in asthma prevalence is thought to be partially due to environmental changes such as changes in air pollution and occupational exposures. Nationally representative information on workplace exposures among US adults with asthma is limited.

METHODS

We examined 2010 National Health Interview Survey data to determine the proportion of employed adults with asthma who had frequent workplace exposures.

RESULTS

Among adults with current asthma, 19.6% frequently worked outdoors, 17.5% were frequently exposed to workplace secondhand smoke and 28.1% were frequently exposed to workplace vapors, gas, dust or fumes. Adults ever told by a health professional that asthma is probably work-related, when compared to adults who were not, had increased odds of frequent work outdoors [prevalence odds ratio (POR)=2.76], frequent workplace exposure to secondhand smoke (POR=3.08) and frequent workplace exposure to vapors, gas, dust or fumes (POR=3.56).

CONCLUSIONS

To our knowledge, this is the first population-based study in USA that estimates the proportion of working adults with asthma that have frequent workplace exposures. Increasing the understanding of workplace exposures among adults with asthma will help enable prevention of asthma through workplace exposure reduction or avoidance. Future studies should further examine industries and occupations of individuals with asthma and frequent workplace exposures.

Distribution of asthma by occupation: Washington State behavioral risk factor surveillance system data, 2006-2009

Objective

Objective: To estimate the prevalence of asthma in workers by occupation in Washington State. Methods: Data from the 2006–2009 Behavioral Risk Factor Surveillance System (BRFSS) and the BRFSS Asthma Call-Back Survey (ACBS) in Washington State (WA) were analyzed. Using state-added and coded Industry and Occupation questions, we calculated prevalence ratios (PRs) for 19 occupational groups. Results: Of the 41 935 respondents who were currently employed during 2006–2009, the prevalence of current asthma was 8.1% [95% confidence interval (CI) 7.8–8.5%] When compared with the reference group of executive, administration and managerial occupations, three occupational groups had significantly (p < 0.05) higher PRs of current asthma: “Teachers, all levels, and Counselors’ (PR 1.3, 95% CI 1.1–1. 6%); ‘Administrative Support, including Clerical” (PR 1. 5, 95% CI 1.2–1.9%); and “Other Health Services” (PR 1.5, 95% CI 1.2–1.9). Half of the 2511 ACBS respondent workers (55.1%) indicated that they believed exposure at work had caused or worsened their asthma, but only 10.7% had ever spoken with a health care professional about their asthma being work related. Conclusions: Some occupations have a higher prevalence of current asthma than other occupations. The systematic collection of industry and occupation data can help identify worker populations with a high burden of asthma and can be used to target disease prevention efforts as well as to aid clinician recognition and treatment. Workers indicated that work-related asthma exposures are not discussed with their health care provider and this communication gap has implications for asthma management.

Occupation held at the time of asthma symptom development

BACKGROUND

Examining occupations other than those held when asthma symptoms first developed may not correctly identify occupations with higher risk of asthma onset.

METHODS

To determine the occupation held when individuals first developed asthma symptoms, we examined 2010 National Health Interview Survey data for working adults with current asthma.

RESULTS

Overall 37.1% of working adults with current asthma developed asthma while employed. Of these, the highest proportions of individuals identified office and administrative support (13.3%), sales and related (9.4%), and management (8.5%) as the occupation held when asthma first developed; 37.8% had a different current occupation than at asthma onset, and estimates of a change in occupation were highest for those who developed asthma while working in business and financial operations (49.3%), sales and related (48.6%), and healthcare support (43.8%) occupations.

CONCLUSION

Future population-based studies should further examine associations between asthma and occupation held at time of asthma onset.

Occupational asthma incidence: findings from the behavioral risk factor surveillance system asthma call-back survey--United States, 2006-2009

BACKGROUND

Occupational asthma (OA) is new-onset asthma or the recurrence of previously quiescent asthma caused by workplace exposures.

OBJECTIVE

To estimate the incidence of population-based new-onset OA and the proportion of incident asthma that is work-related.

METHODS

Behavioral Risk Factor Surveillance System and Asthma Call-back Survey data collected from persons aged ≥18 years during 2006-2009 in 38 states and the District of Columbia were analyzed. Incident health professional-diagnosed new-onset OA cases were persons whose asthma was diagnosed for the first time within the past 12 months whose health professional indicated their asthma was related to their work. Incident potential new-onset OA cases were persons with asthma diagnosed within the past 12 months who did not have health professional-diagnosed work-related asthma but described their asthma as caused by workplace exposures. The proportion of incident asthma that is work-related was calculated using the 2006-2008 estimate of adult asthma incidence (3800 per million).

RESULTS

The estimated annual incidence of health professional-diagnosed new-onset OA was 179 (95% CI: 113-245) per million population. For combined health professional-diagnosed and potential new-onset OA the incidence was 692 (95% CI: 532-853) per million population. The proportion of incident asthma among adults that is work-related was 4.7% for health professional-diagnosed new-onset OA and 18.2% for combined health professional-diagnosed and potential new-onset OA.

CONCLUSIONS

New-onset asthma in as many as one of six adult patients might be associated with work. Clinicians should consider the role of occupational exposures when evaluating adults with incident asthma which may uncover opportunities for early intervention and reversal of an otherwise chronic disease.