Occupational History Quality in Patients With Newly Documented, Clinician-Diagnosed Chronic Bronchitis*

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1 Original Research COPD Occupational History Quality in Patients With Newly Documented, Clinician-Diagnosed Chronic Bronchitis* Ware G. Kuscliner, MD, FCCP; Shainy Hegde, MBBS; and Madhuri Agrau;al, BSc, MSc Background: Approximately 15% of cases of COPD, including chronic bronchitis, is attributable to occupational exposures. An occupational history is essential to identify exposures responsible for work-related chronic bronchitis. Methods: We conducted a structured retrospective analysis ofthe medical records ofveterans, 18 to 70 years of age, newly diagnosed with chronic bronchitis in order to achieve the following: (1) to assess the quality of documented occupational histories; and (2) to characterize the management of patients with a history of exposure to a potentially hazardous respiratory substance. We also analyzed occupational exposure data reported by patients on a structured questionnaire. Results: Sixty patients were included in the final analysis. A total of 6,150 notes were reviewed. Occupational status was documented in the records of 54 patients (90%). A description of occupational duties was recorded in 32 records (53%), and work exposure data in 26 records (43%). Clinicians concluded that occupational exposures potentially contributed to chronic bronchitis in three patients (5%). A recommendation for exposure avoidance was documented for six patients (10%). On the questionnaire, most patients reported a history of occupational exposure to respirable substances and symptoms of cough and/or shortness of breath. Conclusions: Details about job duties and occupational respiratory exposures were documented in the records of approximately half of patients with newly diagnosed chronic bronchitis. Patient self-reports ofoccupational exposures and respiratory symptoms were common. A determination that occupational exposures contributed to chronic bronchitis was rare. Few patients were counseled to take measures to avoid occupational exposures. Work-related chronic bronchitis may be incompletely assessed and undermanaged by clinicians. (CHEST 2009; 135: ) Key words: chronic hronchitis; occnpational exposure; occupational medicine; workplace Abbreviations: ICD-9CM = l utemational Classification or Diseases. ninth revision. clinical modification; PFT = pulmonary function test; VAPAHCS = US Department of Veterans Affairs Palo Alto li"ealth Care System Chronic bronchitis is a disease characterized by cough productive of phlegm on most days for not < 3 months in each of 2 consecutive years. It is associated with air-flow obstruction, dyspnea, and 'From the Pulmonary Section. US Department of Veterans Affairs Palo Alto Health Can' System. Palo Alto, CA. The work was performed at the Veterans Affalrs 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 US Department of Veterans Affairs. The authors have reported to the ACCP that no significant conflicts of interest exist with any companics/orzanlzations whose products or services may h(' discussed in this article. Manuscript received June H; revision accepted August 1, 200H. 378 wheeze.' Chronic bronchitis and emphysema have been historically linked as the two major manifestations of COPD, although recently COPD has been defined as the physiologic finding of nonreversible pulmonary function impairment.f Reproduction of this article is prohihited without written permission from the American College of Clu-st Physicians ( orglmisc/reprints.shtml). Correspondence to: 'Vorl' Kusclincr, MD, FCCP, Veterans Affairs Palo Alto Health Carl' System, 3801 Miranda Avc, Pulmonaru Section, Alail Stop 111 P, Palo Alto, CA 94304; e-ntail: icarc.tcusclincrmduoca.ucn. 001: /chest Original Research

2 While smoking is the most important risk factor for chronic bronchitis, occupational exposures contribute to a large burden of disease. Reports3-5 assessing the role of occupational exposures in the pathogenesis of cord including chronic bronchitis have indicated that 15 to 20% of cases are attributable to respiratory hazards such as vapors, gases, dusts, and fumes that are encountered in the workplace. A diagnosis of chronic bronchitis can only be established by obtaining a medical history. Management of patients should include exploration of disease risk factors, including occupational respiratory exposures, in order to determine whether interventions to reduce toxic exposures may be warranted." Despite the fact that the best instrument for identifying an occupational etiology for a disorder is the occupational history.i-" occupational histories obtained by health-care providers are commonly incomplete.v-? We have previously shown? that clinicians who manage adults with newly diagnosed asthma take incomplete occupational histories and may fail to diagnose work-related asthma. The failure to recognize occupational illness represents a missed opportunity to identify causation and to make important health-care interventions. We conducted a structured retrospective analysis of the medical records of patients with a newly documented diagnosis of chronic bronchitis in order to assess the quality of clinicians' occupational histories and to characterize the management of patients reporting a potentially hazardous respiratory exposure. We included patients with a International Classification of Diseases, ninth revision, clinical modification (ICD-9CM) code for chronic bronchitis code (491) or any related subgroupings of patients that included those with and without air-flow obstruction. Overview. MATERIALS AND METHODS We abstracted demographic, occupational history, and smoking history data from the medical records of patients with a new diagnosis of chronic bronchitis. We compared occupational histories documented by clinicians with occupational exposure data documented by the study patients on a structured self-administered questionnaire. We analyzed pulmonary function test (PFT) results to assess physiologic impairment. 'V'e 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 Patients in Medical Research and the US Department of Veterans Affairs Palo Alto Health Care System (VAPAHCS) Research and Development Committee. Study Setting and Medical Record System The study was conducted at VAPAHCS. VAPAHCS utilizes an electronic health record system. All health-care provider notes and virtually all other elements of patient medical records, including all test results, physician orders, medication lists, and ICD-9CM diagnoses are stored in electronic format. Pulmonary function laboratory questionnaires are among the few documents that are archived as hard-copy paper files. VAPAHCS Pulnumarq Function Laboratory Questionnaire As part of routine clinical care, patients referred to the pulmonary function laboratories of VAPAHCS are directed to complete a structured self-administered questionnaire that ascertains information about pulmonary health. The PFT questionnaire includes domains on pulmonary history and current status, respiratory symptoms (cough and dyspnea), bronchodilator medication usage, smoking history, and occupational exposures (Table 1). The patients' responses to the questionnaire are not included in the PFT study interpretations that are entered into the patients' electronic medical records. Therefore, referring clinicians are effectively blinded to the responses their patients provide on the PFT laboratory questionnaire. Study Population and Data Abstraction We reviewed the medical records of all patients at VAPAHCS who, during the period from January 1, 1999, through March 31, 2008, (1) were 18 to 70 years of age, (2) had a newly reported diagnosis of chronic bronchitis (lcd-9cm code 491) or any related subgroupings, (3) had completed pulmonary function testing, and (4) had completed a PFT laboratory questionnaire that was available for review. We conducted a computerized search to identify patients who met the first two inclusion criteria listed above. Then, we reviewed pulmonary function records to identify those patients who also met criteria 3 and 4. Two investigators (S.H. and M.A.) abstracted individual patient medical records for the time period I-year prior to and l-year following the date of entry of the ICD-9CM code for the diagnosis of chronic bronchitis into the medical record. We searched electronic medical records for the documentation of occupational histories, either formally titled as such or embedded Table I-Domains and Questions Abstracted From the VAPAHCS Pulmonary Function Laboratory Questionnaire Domains and Related Questionnaire Items Occupational history Have you ever worked in a dusty place? Have you ever worked in a mine, quany, or foundry? Have you ever worked near gases or fumes? Smoking history Have you ever smoked cigarettes? Are you currently a smoker? How many packs a day? How many years? Respiratory symptoms Do you ever cough? Do you get short of breath? Medication use Do you use inhalers? What kind? CHEST /135/2/ FEBRUARY,

3 in any part uf the progress notes. Occupational histories were specifically reviewed for documentation of the follow elements: (1) designation of employment status (ie, employed, retired, unemployed, or disabled); and, if ever employed, (2) job title; (3) specific occupational duties; (4) types of occupational exposures; (.5) types of protective equipment used at work; and (6) prior occupational exposure history. Records in which there was documentation of no respiratory exposure history (ie, specific documentation that there were no relevant occupational exposures) were tallied as including documentation of the occupational history element «exposure at work." Our review also included a search for documentation of clinician determination that an occupational exposure may have caused or contributed to chronic bronchitis or symptoms of chronic bronchitis. If an occupational factor was associated with a patient diagnosis of chronic bronchitis, the medical record was reviewed further to determine whether any action was pursued based on this assessment. We reviewed those charts speciflcally for documentation of the following situations: (1) a 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 an intention to contact the employer directly in order to obtain more information; (2) a referral to subspecialty care (eg, pulmonary medicine or occupational medicine) with the specific intention of having the patient evaluated for work-related chronic bronchitis; (3) request for post-work shift or cross-work shift spirometry or peak expiratory air-flow 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 occupational history elements and health-care provider interventions targeted in the chart review were decided on in an a priori manner by the three investigators (S.H., M.A., and W.G.K.). In a post hoc analysis, we compared the frequency of clinician documentation of occupational history elements in patients with normal lung function compared with patients with abnormal lung function. We categorically defined normal lung function as FEYI 2:: 80% predicted. In another post hoc analysis, we tested the following variables, individually and in a multivariate logistic regression model, to determine whether they predicted the absence of occupational exposure history: age; gender; smoking history; current smoking status; and normal lung function (ie, FEY l, > 80% predicted). We also tested for concordance between occupational history documentation by patient and by clinician. We compared the frequencies of positive, negative, and absent histories of exposure to gas, dust, and fumes (patient self-documentation) with exposures at work (clinician documentation). We repeated the analysis eliminating cases in which documentation was absent. Statistical Analysis Data were entered into a spreadsheet (Excel; Microsoft; Redmond, WA). Spreadsheet data were used to calculate the mean values and SDs. The Fisher exact test was used to compare frequencies. Occupational History RESULTS The computerized database query identified 580 patients who had a new diagnosis of chronic bronchitis during the patient identification period. Of these, 354 patients had completed a PFT at VAPAHCS. Of these, 141 patients had also completed a pulmonary function laboratory questionnaire that was recovered from the archives of one of the two VAPAHCS pulmonary function laboratories. A total of 60 patients met the prespecified age inclusion criterion; the remainder exceeded age 70 years. This group of 60 patients comprised the study group. Patient Characteristics and Pulmonary Physiology in the Study Group Table 2 shows the demographic characteristics, smoking status, and pulmonary function characteristics of the study group. Fifty-three patients (88%) were men. The mean (± SD) age was 60.2 years (SD,,5.9 years). Twenty-five patients (42%) were current smokers. The mean FEV] was 55% predicted. Forty-five patients (75%) reported the use of bronchodilators as part of their medication regimen. A total of 6,1.50 notes were reviewed. At least one notation addressing occupational status tie, current or past job titles, or specific documentation that the patient was not employed) was documented at least once in the records of 54 patients (90%). For six patients (10%) with newly diagnosed chronic bron- Table 2-Characteristics ofpatients With Newly Diagnosed Chronic Bronchitis* Characteristics Values Authors (1 Medical Record Notes We identified the professions, specialties, ami titles of the authors of medical record notes. PFT Data We collected the following PFT data from the medical records: (1) FEY l ; and (2) FEY/FYC ratio. Agc, yr Male gender History of ever smoking Current smoking Bronchodilator use FEY,. Us FEY,. % predicted FEY/FYC ratio *Yalues are given as the mean :!: SO :!:.5.9 (18-70).53(88).50 (83) 2.5 (42) 4.5 (7.5) 1.82 :!: :!: :!: 16.0 ± SO (range), No. (%), or mean 380 Original Research

4 Table 3-Health-Care Provider Documentation of Occupational History Elements* Table 4-Distribution, by Professional Status, of Authors ofabstracted Chart Notes* Occupational History Element Charts With Element Note Authors Values Employment status documented Patient currently employed Patient not employed (retired, disabled, or unemployed) No documentation of job title or employment status Occupational duties Exposures at workt Positive history of exposure Negative history of exposure Protective equipment used at work History of occupational exposure Clinician suspicion or diagnosis of an occupational factor contributing to chronic bronchitis or respiratory symptom Recommendation for exposure avoidance (eg, job change or use of respiratory protection) 54 (90) 27 (45) 24 (40) 6 (10) 32 (53) 26 (43) 21 (35),5 (8) 3 (5) 13 (21) 3 (5) 6 (10) *Values are given as No, (%), Patients may have occupational history elements included in more than one category. Therefore, percentages add up to > 100%, t Results include documentation of negative histories (ie, no work exposure). chitis, there was no note entered during the 2-year review period that indicated either a job title or employment status. Additional occupational history details were found in approximately half of the study patients (Table 3). Documentation regarding the presence of potentially significant respiratory exposures at work, including histories negative for exposures iie, specific documentation that there were no relevant exposures), were present in the records of 26 patients (43%). Descriptions of specific work duties were identified in 32 patients (53%). Among patients known to be currently employed (n = 27), there was documentation of patients' occupational duties in 21 medical records (78%) and of occupational respiratory exposure in 18 medical records (66%). Assessments linking occupational exposures to chronic bronchitis and actions to address occupational factors were rare (Table 3). Documentation of suspicion or diagnosis of an occupational factor contributing to chronic bronchitis or respiratory symptoms appeared in the records of only three patients (5%). Six patients (10%) received advice for exposure avoidance due to respiratory symptoms (Table 3). One patient was referred to a claims board. We found no evidence in any record of a referral for legal counsel, a request for additional Health-care provider notes Staff (attending) physicians notes Physicians-in-training notes Nonphysician health-care provided notes DISCUSSION 6,150 (100) 1,028 (17) 692 (11) 4,430 (72) *Values are given as No. (%). t Includes registered nurses, licensed vocational nurses, physician assistants, occupational therapists, physical therapists, podiatrists, and clinical social workers. exposure information (eg, material safety data sheets), or of a Doctor's First Report of Injury being filed. In a comparison of patients with normal and abnormal lung function, we found no significant differences in the frequency of occupational history element documentation (see online supplemental table). Demographic characteristics, smoking status, and lung function did not predict occupational exposure history documentation by clinicians, In a univariate analysis, there was a trend for a positive history of current smoking to predict absence of exposure history documentation that did not achieve statistical significance (p = ). Characteristics ofmedical Record Note Authors Of the 6,150 health-care provider notes that were reviewed, staff (attending) physicians authored 1,028 notes (17%) and physicians-in-training authored 692 notes (11%) [Table 4]. Occupational history elements beyond employment status were obtained primarily from general medical clinics (n = 17; 36%) and pulmonary clinics (n = 23; 48%) [Table 5]. Patient Self-Documentation of Occupational Exposures and Respiratory Symptoms Thirty-five patients (58%) reported histories of occupational exposures to gases or fumes on the self-administered patient PFT questionnaire. Thirtythree patients (55%) reported dust exposure at work. Dyspnea was present in 49 patients (81%), and cough was present in 36 patients (60%) [Table 6]. We found a trend toward an association between occupational history documentation by patient and clinician that did not achieve statistical significance (p = 0.14; weighted K agreement statistic = [range, to ]). When we eliminated cases in which documentation was absent, there was no association (p = 0.27). We conducted a structured review of patient medical records in order to assess the quality of CHEST / 135 / 2 / FEBRUARY,

5 Table 5-Clinic and Provider Information for Patients With an Occupational History Item Other Than Job Title* Clinic and Author Source-s Clinic General medical Pulmonarv H&P admission Cardiology Environmental medicu] GI Neurology Urology ENT Dermatolo!,'Y Audiology Psvchiatrv Behavioral medicine GI live-r behavioral mcdicino MHC C&P Medicine ENT Audiolo!,'y Mental Physiotherapv Emergencv Discharge snmnwry Social work Smoking cessation Telephone earl' Patients with inpatient stay during review periodt Anthor sources Staff (attending) physicians Physicians-in-truining Nonphysician health-care providers: *Values are given as No. (%). Patients Identified 17 (36) 2:3 (4H) 3 (6) 4 (H) :3 (6) 3 (0) 4 (H) 2B (61) 2H (,59) 26 (,55) C&P = Compensation and Pension Examination; ENT = ear, nose, and throat; II&P = history and physical; MIIC = mental health clinic. t No oconputiounl history elements were obse-rved from inpatient progress notes. II ncludes n>gistered nurses, licc-nsc-cl vocational nurses, physician assistants, occupational therapists, physical therapists, podiatrists, and clinical social workers. clinicians' occupational histories in a population of patients at risk for work-related chronic bronchitis. We searched medical notes for specific occupational history elements and for documentation of specific actions taken by health-care providers. We also assessed the prevalence of respiratory symptoms and occupational exposures as documented on a patient self-administered questionnaire. We found the overwhelming majority (90%) of medical records of patients contained at least one note that documented either a specific occupation or occupational status. Additionally, details about job duties and occupational respiratory exposures were documented in the records of approximately half of Table 6-Patient Self-Reports of Occupational Exposures and Respiratory Symptoms* Exposures or Symptoms Worked in mine or foundry Exposure to gas, dust, or fumes Exposure to dusty workplace Congh Shortness of breath Charts With Occupational I Iistorv Element 4 (6) 3.5 (5H) 33 (55) 36 (60) 4B (HI) "Values arc given as No. (%). The data were derived from a patient self-administered questionnaire. Questionnaires are archived in the pulmonary function laboratories of the VAPHACS and are, effectively, unavailable for review hy referring health-care providers. the patients. Determination that a patient's occupation contributed to chronic bronchitis was documented in only 5% of patient records. Despite documentation of a history ofexposure to potentially harmful agents for many patients, few were counseled to take measures to avoid respiratory exposures, We believe that our findings suggest that workrelated chronic bronchitis may be incompletely assessed and undennanaged by clinicians. Our study population may have been at significant risk for work-related chronic bronchitis. Over half of the study population reported occupational exposure to respirable agents. Most patients complained of cough and/or dyspnea, and PFT data showed significant impairment in the study population. We found no difference in occupational history assessments between patients with normal vs abnormal lung function, There was a trend toward clinicians failing to document an exposure history among smokers. We speculate that this finding reflects a bias among clinicians to attribute respiratory symptoms in smokers exclusively to smoking. We found no concordance between clinicians and patients in the documentation of a history of occupational respiratory exposure. An appropriate occupational history includes a description of work duties, the types of current and past exposures at work, the presence of symptoms at work, and, if relevant, the type of protective equipment used at work Ajob title alone does not constitute an adequate occupational history and is insufficient to make a diagnosis of occupational lung disease, An inadequate occupational history may result in a failure to identifydisease etiology or a delay in diagnosisy,li-14 Most patients were either current or fonner smokers. It is possible that clinicians attributed chronic bronchitis to this important exposure and did not consider the possibility of relevant occupational coexposures. Nevertheless, the data from numerous studies indicate the population-attributable percent- 382 Original Research

6 age of risk for the proportion of chronic bronchitis or COPD due to work-related factors is ~ 15%.3-.'5 These data suggest that even among smokers, and perhaps especially among smokers, it is important to consider occupational factors that may contribute to the development of chronic bronchitis. It is possible that some health-care providers believed that exploring a possible connection between chronic bronchitis and occupational exposures was not important because they assumed or confirmed that their patient was not working. However, this explanationwas not explicitly documented in any patient medical record. Consistent with the findings that we previously reported? in an analysis ofpatients with asthma, more detailed occupational histories were documented by staff physicians in pulmonary or general medical clinics. The primary limitation of this study is the lack of a "gold standard" diagnosis for work-related chronic bronchitis and, in tum, the inability to determine the actual prevalence of work-related chronic bronchitis in the study population. We employed a standard screening questionnaire to assess for occupational exposures of potential importance. Our questionnaire did reveal that 58% of patients had a history of occupational exposure to gas, dust, or fumes, which was similar to results from prior surveysv!" that were designed to detect a history ofoccupational exposure in populations of veterans. We cannot exclude the possibility that some cases of chronic bronchitis, though newly identified, had been long-standing. However, this possibility does not exclude the potential usefulness of a complete occupational history at the time of the diagnosis and documentation of chronic bronchitis. In considering all types of chronic cough, occupational chronic cough is regarded as one of the most preventable forms of the disease, underscoring the value of a thorough evaluation of the patient with chronic cough, including a complete occupational history to identify potential etiologic exposures.!" In conclusion, in this population of adults with newly diagnosed chronic bronchitis, health-care providers frequently documented details about job duties, workplace exposures, and other essential elements of the occupational history. Additionally, patient self-reports of occupational respiratory exposures and respiratory symptoms were common. A determination that occupational exposures either caused or contributed to chronic bronchitis was rare. Few patients were counseled to take measures to avoid occupational exposures. Work-related chronic bronchitis may be incompletely assessed and undermanaged by clinicians. ACKNOWLEDGMENT: The authors thank Raymond Balise, PhD, for his advice and assistance with statistical analyses. REFERENCES Pelkonen M. Smoking: relationship to chronic bronchitis, chronic obstructive pulmonary disease and mortality. Curr Opin Pulm Med 2008; 14:10, Global Initiative for Chronic Ohstructive Lung Disease. Global Strategy for Diagnosis, Management, and Prevention of COPD. Availahle at: Guidelineitem.asp?\l =2&12= 1&intId=989. Accessed October 6, Blanc PD, Toren K. Occupation in chronic ohstructive pulmonary disease and chronic hronchitis: an update. Int J Tuberc Lung Dis 2007; 11: Balmes J, Becklake M, Blanc P, et a\. American Thoracic Society statement: occupational contrihution to the hurden of airway disease. Am J Respir Crit Care Med 200,3; 167: Rushton L. Occupational causes of chronic obstructive pulmonary disease. Rev Environ Health 2007; 22: Boschetto P, Quintavalle S, Miotto D, et a\. Chronic ohstructive pulmonary disease (COPD) and occupational exposures. J Occup Med Toxicol 2006; 1:11 7 Newman LS. Occupational illness. N Engl J Med 199.5; 3.3.3: Landrigan PJ, Baker DB. The recognition and control of occupational disease. JAMA 1991; 266: Shofer S, Haus BM, Kuschner WG. Quality of occupational history assessments in working age adults with newly diagnosed asthma. Chest 2006; 130: Harher P, Merz B. Time and knowledge harriers to reeognizing occupational disease. J Occup Environ Med 2001; 4.3: Banerjee D, Kuschner WG. Diagnosing occupational lung disease: a practical guide to the occupational pulmonary history for the primary care practitioner. Compr Ther 200.5;.31: American Thoracic Society. Guidelines for assessing and managing asthma risk at work, school, and recreation. Am J Respir Crit Care Med 2004; 169: Poonai N, van Diepen S, Bharatha A, et a\. Barriers to diagnosis of occupational asthma in Ontario. Can J Public Health 200.5; 96: Santos MS, Jung H, Peyrovi J, et a\. Occupational asthma and work-exacerhated asthma: factors associated with time to diagnostic steps. Chest 2007; 1.31: Schwartz DA, Wakefield DS, Fieselmann JF, et a\. The occupational history in the primary care setting. Am J Med 1991; 90: Groneberg DA, Nowak D, Wussow A, et a\. Chronic cough due to occupational factors. J Occup Med Toxicol 2006; 1: CHEST /135/2/ FEBRUARY,