Key Point

Clinicians who manage adults with newly diagnosed asthma do a poor job documenting occupational factors that may have precipitated the development of asthma. Thus, occupational asthma may be underdiagnosed and undermanaged.

PALO ALTO, CALIF—An estimated 10% to 15% of adult asthma cases can be attributed to workplace exposures, meaning that those cases are preventable. But how can anyone hope to do a good job of preventing occupational asthma when the condition is so frequently overlooked and so poorly documented?

That was the question that Ware G. Kuschner, MD, and associates posed after evaluating the quality of the occupational asthma histories obtained by the health care providers of 197 adults with newly diagnosed asthma.¹ "The quality of the histories was suboptimal," stated Dr. Kuschner, Associate Professor of Medicine at the Stanford University School of Medicine in Palo Alto, California.

"For example, for one quarter of the patients there was no documentation of a job title or even of anything having to do with work," he said in an interview with Pulmonary Reviews. In addition, work-related duties, the use of protective equipment, exposure to hazardous substances, and other vital occupational data were only rarely documented.

Of the study participants, whose average age was 46, 28% were current smokers, 28% had a positive response to albuterol during pulmonary function testing, and 83% used bronchodilators as part of their asthma therapy. Six hundred fifty-nine health care providers were involved in recording the patients’ occupational asthma histories; the majority of the providers (64%) were physicians.

Although employment status was usually documented, specific work-related responsibilities almost never were; they were absent from patient records 95% of the time. A diagnosis of occupational asthma, whether protective equipment was used at work, a recommendation for a change of job, job history, and occupational exposures were documented in 2%, 3%, 3%, 10%, and 11% of cases, respectively.

Notably, among the 122 patients whose employment was documented, 29 (15%) were in settings associated with an increased risk for occupational asthma. Their job titles included construction worker, carpenter, auto mechanic, electronics clean room technician, nurse, custodian, welder, painter, electrician, and farming field worker.

"There was discordance between what clinicians documented in the medical records and what the patients reported about their occupational exposures and respiratory symptoms," Dr. Kuschner stressed. Of the 197 patients assessed, 122 (62%) reported histories of occupational exposures to gases, dusts, or fumes, on a self-administered, structured questionnaire. Exposure to a dusty workplace was reported by 109 patients (55%), dyspnea by 151 patients (77%), and cough by 143 patients (73%).

Occupational risks were largely unaddressed by health care providers, said Dr. Kuschner, who pointed out that the 2% rate of occupational asthma diagnosis in the study was far lower than that of 10% to 15%, which one would expect based on current estimates. He urged clinicians evaluating adults with asthma to take complete occupational histories that include not only job titles but also plenty of details about job responsibilities and occupational exposures.

—Timothy Begany

Reference
1. Shofer S, Haus BM, Kuschner WG. Quality of occupational history assessments in working age adults with newly diagnosed asthma. Chest. 2006;130:455-462.

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