Comparison of clinic models for patients with work-related asthma

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1 Occupational Medicine 2017;67: Advance Access publication 26 July 2017 doi: /occmed/kqx100 Comparison of clinic models for patients with work-related asthma J. C. Lipszyc 1,2,3, F. Silverman 1,3,4,5,6, D. L. Holness 1,3,5,6,7, G. M. Liss 6, K. L. Lavoie 8,9 and S. M. Tarlo 1,2,3,4,5,6,10 1 Institute of Medical Science, University of Toronto, Toronto, Ontario M5S 1A8, Canada, 2 Toronto Western Hospital, Toronto, Ontario M5T 2S8, Canada, 3 Division of Occupational Medicine, St. Michael s Hospital, Toronto, Ontario M5B 1W8, Canada, 4 Li Ka Shing Knowledge Institute, St. Michael s Hospital, Toronto, Ontario M5B 1TB, Canada, 5 Department of Medicine, University of Toronto, Toronto, Ontario M5S 1A8, Canada, 6 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M5T 3M7, Canada, 7 Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael s Hospital, Toronto, Ontario M5B 1TB, Canada, 8 Montreal Behavioural Medicine Centre, Research Centre, Centre Intégré universitaire de santé et de services sociaux du Nord de l Ile (CIUSSS-NIM) Hôpital du Sacré-Cœur de Montréal, Montreal, Québec H4J 1C5, Canada, 9 Université du Québec à Montréal (UQAM), Montreal, Québec H3C 3P8, Canada, 10 University Health Network, Respiratory Division, Toronto, Ontario M5T 2S8, Canada. Correspondence to: S. M. Tarlo, Toronto Western Hospital EW7-449, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. Tel: ; fax: ; susan.tarlo@utoronto.ca Background Work-related asthma (WRA) is a prevalent occupational lung disease that is associated with undesirable effects on psychological status, quality of life (QoL), workplace activity and socioeconomic status. Previous studies have also indicated that clinic structure may impact outcomes among patients with asthma. Aims Methods Results To identify the impact of clinic structure on psychological status, QoL, workplace limitations and socioeconomic status of patients with WRA among two different tertiary clinic models. We performed a cross-sectional analysis between two tertiary clinics: clinic 1 had a traditional referral base and clinical staffing while clinic 2 entirely comprised Worker s Compensation System referrals and included an occupational hygienist and a return-to-work coordinator. Beck Anxiety and Depression II Inventories (BAI and BDI-II), Marks Asthma Quality of Life Questionnaire (M-AQLQ) and Work Limitation Questionnaire (WLQ) were used to assess outcomes for patients with WRA. Clinic 2 participants had a better psychological status across the four instruments compared with clinic 1 (for Beck Anxiety : P < and Depression : P < 0.01, Mood domain of M-AQLQ: NS and Mental Demands domain of WLQ: P < 0.01). Clinic 2 had a greater proportion of participants with reduced income. Conclusions Our study indicates that clinic structure may play a role in outcomes. Future research should examine this in larger sample sizes. Key words Introduction Clinic models; occupational; psychological status; quality of life; socioeconomic status; work-related asthma; work limitations. Work-related asthma (WRA) is a form of adult-onset asthma comprised of occupational asthma (OA) and work-exacerbated asthma (WEA) [1,2]. WRA is associated with adverse effects in psychological status and quality of life (QoL) [3]. Patients with WRA are also more likely to experience limitations in the workplace which may result in higher rates of unemployment and potential loss of income [4,5]. It is often advised that patients with difficult-to-treat asthma (not specifically WRA) should be seen in secondary or tertiary centres where multidisciplinary support is provided to consider other aspects of the patient s condition [6]. A recent study [7] that included patients with difficult-to-treat asthma reported better clinical outcomes and less health care utilization costs in a tertiary multidisciplinary centre [6,7]. Return-to-work (RTW) programmes are also an important component of a treatment plan for those diagnosed with a work-related condition. These The Author Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please journals.permissions@oup.com

2 478 OCCUPATIONAL MEDICINE programmes are associated with a higher rate of RTW, improvements in overall pain and function [8] and lower durations of work disability and costs among those with musculoskeletal, mental health and pain conditions [9]. Multidisciplinary teams play an important role for optimal management of asthma, and WRA is characterized by additional complexities due to a work-related component. RTW intervention may have particular benefit for a patient population with WRA since a significant proportion may need to be removed from their workplace or have their work environment modified to obviate exposure and improve outcomes. The present study aimed to identify differences in psychological status, QoL, socioeconomic status and QoL variables between two distinct tertiary clinic models (clinic 1 [C1], including an asthma educator and clinic 2 [C2], a mutidisciplinary clinic [10]). Methods Our study design has been previously described [11]. We carried out a cross-sectional analysis between the two tertiary clinic models. Baseline demograph ical and clinical variables were obtained through medical records. Information on participants psychological status, QoL, work limitation and socioeconomic status were collected through four previously validated questionnaires: the Beck Anxiety and Depression (II) Inventories (BAI and BDI-II), Marks Asthma Quality of Life Questionnaire (M-AQLQ) and the Work Limitation Questionnaire (WLQ). Participants were recruited between 2013 and 2015 from asthma patients previously assessed in two tertiary clinics. Medical records of clinic patients from C1 from 1991 to 2014 and from C2 from 2002 to 2014 were reviewed to determine eligibility for the present study. The following inclusion criteria were used: (i) an established diagnosis of OA or WEA, (ii) ability to speak and understand English and (iii) accessibility via either phone or mail. The following exclusion criteria were used: (i) a diagnosis of a non-psychiatric comorbidity or psychiatric comorbidity prior to onset of WRA and (ii) inability to speak and understand English. Potential participants previously had an evaluation of their occupational and medical history, underwent a physical examination, pulmonary function testing including spirometry and/or methacholine challenge test and allergy skin prick testing for 15 common allergens. Participants may have also had additional assessments, including allergy skin prick testing for particular suspected workplace agents, serial monitoring of peak flow readings and methacholine challenge tests as appropriate. Potential participants received study documents via the mail. Three weeks later, potential participants were contacted over the telephone to answer any questions and to schedule a time to complete the questionnaires. For the purposes of this study, we combined OA and WEA subgroups to make the comparisons between the clinic models. We used BAI [12] and BDI-II [13] to identify anxiety and depression symptoms and their severity in the previous 2 weeks, respectively. Both have 21 Likert scale items that range in severity from 0 (not at all) to 3 (I could barely stand it). The scores of these two instruments are totalled and yield a score ranging from 0 to 63. The scores were aggregated as follows: 0 9 represented minimal anxiety and 0 13 represented minimal depression; represented mild anxiety and represented mild depression; represented moderate anxiety and represented moderate depression and represented severe anxiety and represented severe depression. M-AQLQ [14] was used to assess asthma-specific QoL impairments in the previous 4 weeks. There are 20 Likert scale items that range in severity from 0 (not at all) to 4 (very severely). There are four domains in which the items are distributed: Health Concerns, Social Disruptions, Breathlessness and Mood Disturbance. This questionnaire has a five-point Likert scale, rather than the seven-point Juniper s AQLQ [15]. The WLQ [16] was used to ascertain the extent of impairment in the workplace. There are 25 Likert scale items that range from 0% (none of the time) to 100% (all of the time). The items assess the level of difficulty on a number of job demands in the previous 2 weeks. The WLQ consists of four domains: Time Demands, Physical Demands, Mental-Interpersonal Demands and Output Demands. All questionnaires that were administered in the present study have been previously validated and have high levels of internal consistency [14,16 18]. The two clinics were characterized by different teams of professional personnel, with the exception of the respiratory physician (who was the same at both clinics). Referral patterns also differed between the clinics. Main differences between C1 and C2 are outlined in Table 1. As part of the health care team in C2, the return-towork coordinator (RTWC) initially consults with the specialist physician to determine if the patient would benefit from stay at work or RTW services. Such services were usually considered for patients when the respiratory physician recommended a change from the current job description or job location with the same employer. Roles of the RTWC include: (i) maximizing the fit between the worker, work environment and job duties, (ii) co-ordinating the process of communication between all relevant parties, (iii) assessing barriers and facilitators to successful work outcomes for the worker and workplace, (iv) outlining a feasible RTW plan based on the relevant medical and exposure information, (v) visiting the workplace as necessary, (vi) monitoring progress and consulting with all parties as needed and (vii) educating all parties. An occupational hygienist (in C2) obtains a detailed workplace description, including the type of employment,

3 J. C. LIPSZYC ET AL.: CLINIC MODELS FOR PATIENTS WITH WORK-RELATED ASTHMA 479 Table 1. Characteristics of the two clinics C1 C2 Medical focus Professional personnel a industry/sector, work history and the hourly schedule of the patient, personal protective equipment use and its suitability. A respiratory therapist (in C1) educates patients on how to adequately use and adhere to their medication and teaches patients self-management techniques to avoid future exacerbations [19]. All data were analysed using the Statistical Package for the Social Sciences (SPSS) for Windows, Version 20.0 (IBM Corporation, Armonk, NY). Descriptive variables such as baseline demographical data, clinical information and socioeconomic status were analysed using the student s independent t-test for continuous data, and chi-square (χ 2 ) tests for categorical data. Questionnaire data were compared between the two clinic models (C1 and C2) using student s independent t-test for variables with Gaussian distributions. Questionnaire data that were characterized by a non-gaussian distribution were compared using non-parametric Mann Whitney U-tests. Results were considered significant at the 0.05 level. All data are expressed as a mean ± 1 SD. The study received approval from Research Ethics Boards at University Health Network, St. Michael s Hospital and University of Toronto. Results Focus on respiratory disease (asthma, WRA and other respiratory and allergic diseases). Clinic personnel include: respirologist and respiratory therapist. Of the 166 eligible patients across the two clinic sites, 47 patients were recruited from C1 and 30 from C2. The percentage response rate was 46%. Non-participants included those that refused (n = 19), died (n = 1), had a wrong telephone number or the telephone number was no longer in service (n = 49) or who could not otherwise be reached successfully (n = 20). Characteristics of participants are provided in Table 2. At C1, there were 29 OA cases (62%) and 18 WEA cases (38%) and C2 participants included 21 OA cases (70%) and nine WEA cases (30%). The C2 Focus on occupational disease. Clinic personnel include: respirologist or allergist, RTWC (occupational therapist) and occupational hygienist. Patient follow-up Follows patients over an extended period of time. Often includes a single clinic visit without further in-clinic follow-up (unless deemed appropriate). Referrals Typically receives referrals from specialists and general practitioners. Receives referrals only from the WSIB. a The same respirologist assessed patients at both C1 and C2. Referrals are for diagnosis and management of WRA. Referrals are complex workers compensation cases that include confusion about diagnosis and work-relatedness, or with problems with staying at or returning to work. sample also saw a trend toward a more recent diagnosis compared with C1 (as expected due to the more recently established clinic at C2). The majority of the overall working sample (63%) was working for a different employer and no longer exposed to the initial agent associated to their condition. The C2 clinic sample had a greater proportion of patients with a decrease in income following asthma diagnosis compared with C1 (borderline statistical significance) and none were presently working in conditions with the exposure considered responsible for their asthma. Roughly half of all participants (52%) had an active WSIB (Workplace Safety and Insurance Board) claim (for example, receiving partial income, or medication coverage) at the time of the study. We found a greater proportion of employed patients had their first clinic appointments at C1 compared with C2 as reported in Table 2. On average, participants at C2 were older than those seen at C1. There were no other significant differences in baseline characteristics between participants in the two clinics. Participants at C2 endorsed lower levels of anxiety compared with those at C1 (Table 3). The mean of the anxiety scores fell within the minimal range for those at C2, and the mild range for C1 participants. There were 13 (28%) participants from C1 and 4 (13%) participants from C2 that scored 16 on the BAI, indicating clinically significant levels of anxiety. As shown in Table 3, results from those at C2 indicated lower levels of depression compared with C1 participants, again falling within the minimal range for those at C2, and the mild range for C1 participants. There were 19 (40%) participants from C1 and eight (27%) participants from C2 that scored 12 on the BDI, indicating clinically significant levels of depression. There was a significant positive correlation between the depression and anxiety scores across both sites (P < 0.001).

4 480 OCCUPATIONAL MEDICINE Table 2. Demographic, clinical, socioeconomic and occupational characteristics of the sample at the time of the study (represented by means, percentages and SDs) Characteristics Both sites (n = 77) C1 (n = 47) C2 (n = 30) P value Male (%) 48 (62) 27 (57) 21 (70) NS Mean age (years) 56.8 ± ± ± 11.1 NS Mean age at first appointment 50.2 ± ± ± 9.4 P < 0.05* Mean time since symptom onset (years) 13.0 ± ± ± 6.5 NS Mean time since diagnosis (years) 9.3 ± ± ± 6.0 NS Marital status, n (%) Single 10 (13) 6 (13) 4 (13) } Married 60 (78) 37 (79) 23 (77) } Widowed 1 (1) 0 (0) 0 (0) }NS Divorced 3 (4) 2 (4) 1 (3) } Separated 3 (4) 2 (4) 2 (7) } Education level, n (%) Grade (44) 20 (43) 14 (47) } Vocational training 5 (7) 3 (6) 2 (7) }NS College or university 38 (49) 24 (51) 14 (47) } Employment and exposure status among workers, n (%) Same exposure and employer 7 (17) 7 (28) 0 (0) } No exposure and same employer 8 (20) 3 (12) 5 (31) } Different employer, no exposure and part time status 4 (10) 2 (8) 2 (13) }NS Different employer, no exposure and full time status 22 (54) 13 (52) 9 (56) } Working status at first appointment, n (%) Working 55 (72) 38 (81) 18 (60) } Not working 22 (28) 09 (19) 12 (40) }P < 0.05* RTW intervention N/A N/A 12 (41) N/A Income change following symptom onset, n (%) Increased 7 (9) 4 (9) 3 (10) } Unchanged 31 (40) 24 (52) 7 (23) }P < 0.05* Decreased 39 (51) 19 (40) 20 (67) } Income change following symptom onset excluding retirees (n = 27 for patients not working), n (%) Increased 5 (10) 2 (6) 3 (16) } Unchanged 24 (48) 19 (59) 5 (28) }NS Decreased 21 (42) 11 (34) 10 (56) } Supported by WSIB at time of the study (yes), n (%) 40 (52) 24 (51) 16 (53) NS FVC, % predicted, initial At work 91.4 ± ± ± 18.9 } Off work 89.3 ± ± ± 20.0 }NS FEV1, % predicted initial At work 76.6 ± ± ± 25.7 } Off work 78.2 ± ± ± 20.9 }NS FEV1/FVC initial At work 68.3 ± ± ± 13.6 } Off work 71.0 ± ± ± 8.9 }NS Values are expressed as mean ± SD. Analyses were carried out using the student s independent t-test for continuous variables, and chi-square tests for categorical variables. FVC, forced vital capacity; FEV1, forced expiratory volume in 1 s; N/A, not applicable; NS, non-significant. *Significant results at P = For QoL, no significant differences were found between the two clinics for the total mean of the four domains, and the following domains: Breathlessness, Social Disruptions and Concerns for Health. Participants at C1 had a trend toward a worse score compared with those at C2 for the Mood domain although this was not statistically significant. The mean values for the four domains of the BDI-II were 1.09 and 0.98 (falling within mild range or the least severe on the scale) for C1 and C2, respectively. For work limitations, no significant differences were found between the two clinics for the total mean of the four subscales, and the following subscales: Time Demands, Physical Demands and Output Demands. For Mental Demands, participants at C1 scored worse than those at C2 (P < 0.01) in an analysis that excluded retired patients (for those patients still working, n = 32 for C1 and n = 18 for C2). The mean percentile ranking of participants on the four subscales of the WLQ were 28 and 16% for C1 and C2, respectively (excluding

5 J. C. LIPSZYC ET AL.: CLINIC MODELS FOR PATIENTS WITH WORK-RELATED ASTHMA 481 Table 3. Comparisons between the two clinics for the following questionnaire data: BAI, BDI-II, M-AQLQ and WLQ Questionnaire values Both sites (n = 77) C1 (n = 47) C2 (n = 30) P value BAI 10.5 ± ± ± 7.11 P < 0.001* BDI-II 10.9 ± ± ± 8.4 P < 0.01* M-AQLQ Mean of all domains 1.05 ± ± ± 0.86 NS Breathlessness 0.99 ± ± ± 0.97 NS Health Concerns 1.05 ± ± ± 0.88 NS Social Disruptions 1.25 ± ± ± 1.04 NS Mood Disturbance 0.88 ± ± ± 0.84 NS WLQ (excluding retirees) Mean of all domains 23.5 ± ± ± 17.6 NS Time Demands 292. ± ± ± 24.7 NS Physical Demands 26.1 ± ± ± 23.9 NS Output Demands 20.5 ± ± ± 22.4 NS Mental-Interpersonal Demands 18.2 ± ± ± 14.6 P < 0.01* Values are expressed as mean ± SD. Analyses were carried out using the non-parametric Mann Whitney U-tests. NS, non-significant. *Significant results at P = retirees), where higher scores indicate worse impairment in the workplace. Six (20%) of the 30 participants at C2 were seen in the clinic prior to the introduction of the RTWC and did not have this support available at the time. Twelve of the remaining 24 participants from C2 (50%) received RTW services. Those who participated in RTWC service (n = 12) had a better psychological status (P < 0.01 for Beck Anxiety and P < 0.05 for Beck Depression ), and comparable QoL and work limitation status compared with patients at C1, with the exception of mental demands which were higher for C1 patients (P < 0.05). The small number who received the RTW service demonstrated no significant differences on all questionnaire scores compared with C2 participants who did not receive this intervention. Discussion Our primary findings indicate that a tertiary clinic (C2), with a RTWC and hygienist, was associated with a better psychological status, less psychological impairment in the workplace and less mood disturbances in their QoL compared with C1. However, on average, participants from C2 indicated a worse socioeconomic status compared with those attending C1. In our study, the mean anxiety and depression scores of the BAI and BDI-II were significantly milder among C2 participants compared with those at C1. There were also differences between the two clinics in the number of participants that experienced clinically significant levels of psychological symptoms. Our study reported a higher proportion of participants at C1 that experienced clinically significant levels of anxiety and depression [20,21] compared with those at C2. The better psychological status among C2 participants may be partially attributed to the clinic model, but it is important to be cognizant of other contributing factors. First, participants at C2 tended to be older, and the prevalence of anxiety and depression disorders may decrease with age [22,23]. The C2 sample contained a greater proportion of retirees compared with C1, and retirement is associated with a therapeutic effect on mental health [24]. Participants from C2 demonstrated fewer mood disturbances, compared with C1 participants. One study [25] that evaluated QoL using M-AQLQ among WEA patients reported a mean score of 2.43 which was more severe than that of participants in our study. A recent study [26] that assessed QoL in bakers diagnosed with OA using Juniper s AQLQ reported a mean score of 6.2, a low level of severity for that particular instrument. The level of workplace limitations was lower among C2 participants, although the overall difference was not significant. Those at C2 scored better specifically on the Mood domain. Our findings are less severe compared with a previous study [27] that used the same instrument and reported a mean limitation percentile of 28 and 26% for OA and WEA patients, respectively. The RTWC included in the team at C2 may have played a role in the lower level of impairment and did provide some patients with appropriate support systems and preventive strategies to avoid further limitations in the workplace. From participants reports relating to their initial visit, there was a much greater proportion at C2 that were not working compared with those at C1. This may be partially due to the fact that those in C2 are directly referred from the workers compensation system and are more often already off work due to medical reasons. There were also a greater proportion of participants at C2 with a reduction in income compared with C1. This is also likely associated with the corresponding greater number of participants not working. This in part may relate to the difference in referral criteria, as those referred to C2 were referred in part because of RTW issues. In general,

6 482 OCCUPATIONAL MEDICINE the financial burden revealed by the two clinics was substantial, consistent with previous literature. Vandenplas [5] reported in a review that 44 74% of OA workers had a loss of income associated with their condition. The current study has a number of important strengths. Across the two clinics, the time since diagnosis was ~9 years. Most studies exploring these variables among WRA patients typically do so at a shorter follow-up time post-diagnosis. Our study was able to follow-up with patients many years post-diagnosis, and we reported insights on long-term outcomes. Second, no study to date has explored the impact of clinic structure on the variables we investigated among patients diagnosed with WRA. Providing multidisciplinary support to patients may be important to achieve optimal management, avoid future exacerbations and improve outcomes. Third, the two clinic samples were evaluated primarily by the same respirologist and this helps ensure that the clinical practices were comparable. Our study also has limitations that need to be addressed and considered for future studies. First, our sample sizes were small (such as the number of patients with intervention by the RTWC), that limited the identification of significant findings for certain variables, and also likely impacts the representativeness of our results. Second, an inclusion criterion was English comprehension, and this may have led to a culturally narrower population. Third, we had a substantial number of retired patients, but we corrected this when looking at work limitation outcomes. Fourth, across the two clinics, we reported a 46% response rate which indicates that there may be a potential for selection bias and response bias. The long follow-up time (mean 9 years) likely played a role in the difficulty contacting potential participants. Finally, we did not collect any additional clinical information when this study was carried out and also cannot rule out other life factors that may have influenced the results. In conclusion, we suggest that more effective workplace strategies could be used to mitigate the undesirable effects WRA has on patients. Future research could examine the variables we explored in larger and more homogenous groups, and among patients who were more recently diagnosed. Key points The clinic model and structure may play a role in influencing outcomes for patients with workrelated asthma. A clinic model which includes return-to-work intervention was associated with less psychological impairment among patients with work-related asthma. Future research should consider the impact clinic models have on patients with larger sample sizes and a more homogenous group. Funding This work was supported in part by the Center for Research Expertise in Occupational Disease, funded by the Ontario Ministry of Labour and from graduate student awards including the Ontario Graduate Scholarship and Institute of Medical Science Graduate Entry Award, University of Toronto to J.C.L. Acknowledgements We would like to thank all participating patients. Conflicts of interest S.M.T., G.M.L. and D.L.H. received research funding from the Ontario Ministry of Labour and Workplace Safety and Insurance Board. References 1. Tarlo SM, Lemiere C. Occupational asthma. N Engl J Med 2014;370: Henneberger PK, Redlich CA, Callahan DB et al.; ATS Ad Hoc Committee on Work-Exacerbated Asthma. An official American Thoracic Society statement: work-exacerbated asthma. Am J Respir Crit Care Med 2011;184: Miedinger D, Lavoie KL, L Archevêque J, Ghezzo H, Zunzunuegui MV, Malo JL. Quality-of-life, psychological, and cost outcomes 2 years after diagnosis of occupational asthma. 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