Quality of LifeQuality of Life&&

Disability AssessmentDisability Assessment

Kenneth D. Rosenman, MDKenneth D. Rosenman, MD

Professor of MedicineProfessor of Medicine

Michigan State UniversityMichigan State University

Health-RelatedHealth-RelatedQuality of Life QuestionnairesQuality of Life Questionnaires

www.qolid.org- 437

Generic - 75

Medical Outcome Study

Short Form Health Survey (SF-20)

(Carver et al, 1999)

Asthma - 20

Mini-Asthma Quality of Life

(Juniper et al, 1999)

Uses in LiteratureUses in LiteratureQOL Health QuestionnairesQOL Health Questionnaires

for Asthmafor Asthma

•Impact of pharmacological treatment

•Impact of allergy specialist care

•Pollen vs. non pollen season

•Clinical evaluation

Malo et al, 1993Malo et al, 1993

134 OA (Quebec 1986-1988 on W.C.)

91 Asthma – 2 tertiary care hospitals

OA 2.9 vs. 2.3* Asthma

Limitations

•All compensated (only 8% unemployed)

•Possibility of exaggeration in responses because of compensation

Percentage of Patients with Work-Related Percentage of Patients with Work-Related Asthma Not WorkingAsthma Not Working

Location Number Percent Reference

Ontario 55 36% Yassi, 1988

Brompton 79 33% Venables et al, 1989

Birmingham 112 35% Gannon et al, 1993

Quebec 33 25% DeWitte et al, 1994

Brompton 87 OA

26 AA

65 A

39%

31%

32%

Cannon et al, 1995

Paris 209 28% Ameille et at, 1997

Boston 55 69% Gassert et al, 1998

Sword 770 46% Ross & McDonald, 1998

Belgium

SIC

⊝ SIC

86

71

38%

46%

Larbanois et al, 2002

Work Status of Work-Related Asthma Work Status of Work-Related Asthma in Michigan, SENSOR, 1988-2003in Michigan, SENSOR, 1988-2003

Number Percent

Working Same Company 904 63%

Workers’ Comp 56 4%

Sick/Disability Leave 247 17%

Fired 81 6%

Quit on Doctor’s Advice 78 5%

Quit on Own Because of Asthma 41 3%

Quit on Own 35 2%

TOTAL 1,442

WC/Sick Leave – 21%

Fired/Quit - 16% → 9%

Percentage of PatientsPercentage of PatientsReporting Income LossReporting Income Loss

Location Number Percent Reference

Ontario 55 72% Yassi, 1988

Brompton 79 49% Venables et al, 1989

Birmingham

112 63% Gannon et al, 1993

Brompton 87 OA

26 AA

65 A

61%

65%

36%

Cannon et al, 1995

Paris 209 46% Ameille et al, 1997

Pavia 11 44% Moscato et al, 1999

Belgium

⊕ SIC

⊖ SIC

86

71

62%

59%

Larbanois, 2002

Hospitalizations for Asthma Among Hospitalizations for Asthma Among Individuals with Work-Related AsthmaIndividuals with Work-Related Asthma

Location Number Percent Reference

Ontario 844 15 (8) Liss et al, 2000

SENSOR RADS 105 39 Henneberger et al, 2003

Non AA 279 28

ED Visit

SENSOR RADS 109 78 Henneberger et al, 2003

Non AA 282 48

Risk Factors for Poor PrognosisRisk Factors for Poor Prognosis

• Increased duration of exposure• Increased duration of symptoms before diagnosis• Increased severity of disease at diagnosis

– More baseline airway obstruction– React to lower dose methacholine

• Continued exposure after diagnosis

• Absence of IgE antibody to TDI-Human Serum Albumin Conjugate (Park and Nahm, 1997)

• Eosinophils in BAL (Paggiaro et al, 1993)

Risk Factors for UnemploymentRisk Factors for Unemployment

• Older/Younger• Compensation claim• Less education• Small company (Ameille et al, 1997)• Women (Gassert et al, 1998)• Industrial worker (Gassert et al, 1998)• Chest doc vs. occupational doc (Ross & McDonald, 1998)• Low molecular weight compound,

particularly in smokers (Ross & McDonald, 1998)

Quebec System of Compensation for Occupational Quebec System of Compensation for Occupational Asthma: Criteria Used to Determine Permanent Asthma: Criteria Used to Determine Permanent

DisabilityDisability

Class

Level ofBronchial

Obstruction(% pred)

Level ofBronchial

Responsiveness(mg/ml)

Need forMedication

PercentageDisability*

1 > 85 > 16 None 02A > 85 2-16 None 52B > 85 2-16 BDT PRN 82C > 85 2-16 BDT Daily 102D > 85 0.25-2 None 102E > 85 0.25-2 BDT 132F > 85 < 0.25 BDT 153A 71-85 >16 BDT 183B 71-85 0.25-2 BDT 203C 71-85 < 0.25 BDT 254A 56-70 > 0.25 BDT 284B 56-70 < 0.25 BDT 335A 40-55 >0.25 BDT 505B 40-55 < 0.25 BDT 606 < 40 < 16 BDT 100

*Add3% Inhaled steroids10% Oral steroids

(Malo; Chest 1990)

Impairment Classification for Asthma SeverityImpairment Classification for Asthma Severity

Score

Post-

bronchodilator

FEV1

% FEV1

Change

(Reversibility)

or

PC20 mg/mL or Equivalent

(Degree of Airway

Hyperresponsiveness) Minimum Medication

0> Lower limit

of normal< 10% > 8 mg/mL No medication

1> 70%

of predicted10-19%

8 mg/mL to

> 0.6 mg/mLOccasional but not daily bronchodilator and/or occasional but not daily cromolyn

260-69%

of predicted20-29%

0.6 mg/mL to

> 0.125 mg/mL

Daily bronchodilator and/or daily cromolyn and/or daily low-dose inhaled corticosteroid (< 800 µg of beclomethasone or equivalent)

350-59%

of predicted> 30% < 0.125 mg/mL

Bronchodilator on demand and daily high-dose inhaled corticosteroid (> 800 µg of beclomethasone or equivalent) or occasional course (one to three courses a year) of systemic corticosteroid

4< 50%

of predicted… …

Bronchodilator on demand and daily high-dose inhaled corticosteroid (> 1000 µg of beclomethasone or equivalent) and daily or every other day systemic corticosteroid

(AMA, 5th ed, 2001)

Impairment Rating for AsthmaImpairment Rating for AsthmaAMA (2001) ATS (1993)

Total Asthma Score

Percent

Impairment

Class

Impairment

of the Whole

Person Score Impairment Class

0 1 0% 0 0

1-5 2 10-25%1-3

4-6

1

2

6-9 3 26-50% 7-9 3

10-11 or asthma not controlled despite maximal treatment, ie, FEV1 remaining < 50% despite use of > 20 mg/day of prednisone

4 51-100% 10-11

Not Controlled

4

5

Social Security DisabilitySocial Security Disability(SSA Pub No. 64-039, 1998)(SSA Pub No. 64-039, 1998)

Attacks occurring at least 6x/year despite adherence to prescribed treatment(hospitalization > 24 hrs = 2 attacks)

Spirometric results between attacks document baseline airflow obstruction (severity not specified)

Documentation of adherence to prescribed meds

(Chan-Yeing et al, 1999)

Class of Respiratory Impairment F

EV

1E

OS

%

PC

20N

O

Worker Compensation Claims for Worker Compensation Claims for Work-Related Asthma, United StatesWork-Related Asthma, United States

State of Washington, 1995-20021,377 work-related asthma claims

59% accepted (vs. 90% overall)(33% orchards to 100% electroplating or boilermaking)

(Curwick and Bonauto, 2003)

State of Michigan, SENSOR, 1988-2002818 of 1,740 (47%) applied

51% Pending34% Awarded15% Denied (Rosenman et al, 2003)

State of California, SENSOR, 1993-199658 of 141 (41%) applied (Reinisch et al, 2001)

Total Costs for Work-Related Asthma, USA, Total Costs for Work-Related Asthma, USA, Billions of 1996 Dollars, Assuming a 15% PARBillions of 1996 Dollars, Assuming a 15% PAR

Categories

Direct $1.1726 (74% of total)

Medical Only $1.0238

Administration for Medical Insurance $0.1266

Administration for Indemnity Insurance

Indirect

$0.0222

$0.4041 (26% of total)

Earnings $0.2954

Fringe Benefits $0.0687

Home Production $0.0400

TOTAL $1.5767 billion(Leigh et al, 2002)

SummarySummary

• Only a single study using QOL instrument• Percentage out of work/economic loss is high

– True for all types of work-related asthma

• Variations in socio/economic losses across geopolitical boundaries

• Implementation and evaluation of interventions to reduce adverse health and socio/economic complications