1. Quality of Life & Disability Assessment Kenneth D. Rosenman, MD Professor of Medicine Michigan State University

2. Health-Related Quality 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)

3. Uses in Literature QOL Health Questionnaires for Asthma Impact of pharmacological treatment Impact of allergy specialist care Pollen vs. non pollen season Clinical evaluation

4. Malo 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

5. Percentage of Patients with Work-Related Asthma Not Working LocationNumberPercentReference Ontario5536%Yassi, 1988 Brompton7933%Venables et al, 1989 Birmingham11235%Gannon et al, 1993 Quebec3325%DeWitte et al, 1994 Brompton87 OA 26 AA 65 A 39% 31% 32% Cannon et al, 1995 Paris20928%Ameille et at, 1997 Boston5569%Gassert et al, 1998 Sword77046%Ross & McDonald, 1998 Belgium  SIC ⊝ SIC 86 71 38% 46% Larbanois et al, 2002

6. Work Status of Work-Related Asthma in Michigan, SENSOR, 1988-2003 NumberPercent Working Same Company90463% Workers’ Comp564% Sick/Disability Leave24717% Fired816% Quit on Doctor’s Advice785% Quit on Own Because of Asthma413% Quit on Own352% TOTAL1,442 WC/Sick Leave – 21% Fired/Quit - 16% → 9%

7. Percentage of Patients Reporting Income Loss LocationNumberPercentReference Ontario5572%Yassi, 1988 Brompton7949%Venables et al, 1989 Birmingham11263%Gannon et al, 1993 Brompton87 OA 26 AA 65 A 61% 65% 36% Cannon et al, 1995 Paris20946%Ameille et al, 1997 Pavia1144%Moscato et al, 1999 Belgium ⊕ SIC ⊖ SIC 86 71 62% 59% Larbanois, 2002

8. Hospitalizations for Asthma Among Individuals with Work-Related Asthma LocationNumberPercentReference Ontario84415 (8)Liss et al, 2000 SENSORRADS 10539Henneberger et al, 2003 Non AA 27928 ED Visit SENSORRADS 10978Henneberger et al, 2003 Non AA 28248

9. Risk 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)

10. Risk 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)

11. Quebec System of Compensation for Occupational Asthma: Criteria Used to Determine Permanent Disability Class Level of Bronchial Obstruction (% pred) Level of Bronchial Responsiveness (mg/ml) Need for Medication Percentage Disability* 1> 85> 16None0 2A> 852-16None5 2B> 852-16BDT PRN8 2C> 852-16BDT Daily10 2D> 850.25-2None10 2E> 850.25-2BDT13 2F> 85< 0.25BDT15 3A71-85>16BDT18 3B71-850.25-2BDT20 3C71-85< 0.25BDT25 4A56-70> 0.25BDT28 4B56-70< 0.25BDT33 5A40-55>0.25BDT50 5B40-55< 0.25BDT60 6< 40< 16BDT100 *Add 3% Inhaled steroids 10% Oral steroids (Malo; Chest 1990)

12. Impairment Classification for Asthma Severity Score Post- bronchodilator FEV 1 % FEV 1 Change (Reversibility) or PC 20 mg/mL or Equivalent (Degree of Airway Hyperresponsiveness)Minimum Medication 0 > Lower limit of normal < 10%> 8 mg/mLNo medication 1 > 70% of predicted 10-19% 8 mg/mL to > 0.6 mg/mL Occasional but not daily bronchodilator and/or occasional but not daily cromolyn 2 60-69% of predicted 20-29% 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) 3 50-59% 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, 5 th ed, 2001)

13. Impairment Rating for Asthma AMA (2001)ATS (1993) Total Asthma Score Percent Impairment Class Impairment of the Whole PersonScoreImpairment Class 010%00 1-5210-25% 1-3 4-6 1212 6-9326-50%7-93 10-11 or asthma not controlled despite maximal treatment, ie, FEV 1 remaining 20 mg/day of prednisone 451-100%10-11 Not Controlled 4545

14. Social Security Disability (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

15. (Chan-Yeing et al, 1999) Class of Respiratory Impairment FEV 1 EOS% PC 20 NO

16. Worker Compensation Claims for Work-Related Asthma, United States State of Washington, 1995-2002 1,377 work-related asthma claims 59% accepted (vs. 90% overall) (33% orchards to 100% electroplating or boilermaking) (Curwick and Bonauto, 2003) State of Michigan, SENSOR, 1988-2002 818 of 1,740 (47%) applied 51% Pending 34% Awarded 15% Denied (Rosenman et al, 2003) State of California, SENSOR, 1993-1996 58 of 141 (41%) applied (Reinisch et al, 2001)

17. Total Costs for Work-Related Asthma, USA, Billions 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)

18. Summary 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