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Prof. İbrahim AKKURT, MD Cumhuriyet University Medical School Dept. of Chest Diseases

DISABILITY EVALUATION OF RESPIRATORY DISEASES “Turkish Thorasic Society –TTS- Guidelines of Respiratory Diseases Disability Evaluation ”. Prof. İbrahim AKKURT, MD Cumhuriyet University Medical School Dept. of Chest Diseases SİVAS-TURKEY. Topics. Questions... Problems... Cases...

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Prof. İbrahim AKKURT, MD Cumhuriyet University Medical School Dept. of Chest Diseases

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  1. DISABILITY EVALUATION OF RESPIRATORY DISEASES“Turkish Thorasic Society –TTS- Guidelines of Respiratory Diseases Disability Evaluation ” Prof. İbrahim AKKURT, MD Cumhuriyet University Medical School Dept. of Chest Diseases SİVAS-TURKEY

  2. Topics • Questions... Problems... Cases... • Historical approach • General approach to “disability evaluation” • General and specific situations • TTS Guidelines of Respiratory Diseases Disability Evaluation • Conclusions and suggestions…

  3. * 5 frequently seen respiratory diseases (RTract. Inf., COPD, TB, Lung ca, Asthma) cause: - 17.4% all of the death - 13.3% all of the disability WHO Report 2000 AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 45:338 –345 (2004) The Workers’ Compensation System: Worker Friend or Foe? Lee Strunin,PhD and Leslie I.Boden,PhD

  4. - Akkurt İ ve ark. Akciğerhastalıklarında maluliyet sorunu.Tüberküloz ve Toraks 1995; 43(3): 172-83 - Akkurt İ. MeslekHastalıkları Hastanelerine işlerlikkazandırılması konusunda genel görüşler.Toplum ve Hekim 1996;11:50-56 - Akkurt İ ve ark. Differences in disability evaluation between different countries. Eur Respir J 1997;10(Suppl.25):468s - Akkurt İ ve ark. Maluliyet almış Kömür İşçisi Pnömokonyozu ve Silikosislikişilerde yaşam süresini etkileyen faktörler. Toplum ve Hekim1997;12(77):17-21 -Akkurt İ ve ark. Pnömokonyozda maluliyetdeğerlendirmesi(Almanya ile Türkiye arasındafarklılıklar). SolunumHastalıkları 1998;9(4): 745-52 -Karadağ ÖK, Akkurtİ, Ersoy N.Meslek Hastalıklarının tespit edilememesinin nedenleri ve dogurdugu sonuçlar. Toplum ve Hekim 1998; 13(3):185-9 -Karadag ÖK,Akkurt İ, Ersoy N. Meslek Hastalıklarında sorunlar ve çözümönerileri.Toplum ve Hekim 1998;13(3):191-5 -Akkurtİ. Mesleki Astım(Mediko-legal yönden 47 olgunun retrospektif olarak irdelenmesi). Solunum Hastaliklari 2000;11: 256-61 - Akkurt İ. Pnömokonyozda ILO standartlarında radyolojik değerlendirme. Toraks Degisi, 2001; 2(2):62-71 * 1992- SSS AODH : Pnomoconiosis Disability* 1994- SSS Ank.Teaching Hospital: Disability ???

  5. Int J Occup Environ Health 2004;10:1-12

  6. CASE-1/COPD • Male, 65 years old • Last 5-6 years under COPD treatment, • Have Symptoms, clinical, and radiological findings for COPD... • PFTs: Moderate obstructive defects.... • ABG: Mild hypoxemia + hypercapnia findings • Decision: • SSS: • No disability... • Pension Fundation: • Disability....40% • TTS : • Disability…30-45%

  7. Case-2: Occupational asthma • Male, 34 years old, painter for 10 years • Last 2 years had many asthma attacks. Had been hospitalizated several times for his health problems. He used long action beta-2 mimetic and steroids. • Physical examinationNormal, PFTsNormal • BPT positive(PC20: 0.125mg/ml) • PEFmeters positiveOccupational asthma

  8. Case-2: Occupational asthma Decision: No disability treatment + recomended to work at no irritant area(suggested changing primary work area) Result: No permission to change work place by employer !.... 6 month later died from asthma attack.... • SSS: • No disability • Pension Fundation: • No disability • TTS • -For same work place...100% • For asthma:10-25%

  9. Case-3: Coal Workers Pneumoconiosis(CWP) • Male, 40 years old, For 10 years working in a coal mine • No symptoms, No Physical examination findings • PFTs.... Normal • X-Ray(according to ILO classification): q/q 1/0 • Decision: • SSS • Disability…10.2% • Pension Fundation • Not applicable • TTS • No disability

  10. Historical process...

  11. USA: Disability and compensation system began regionally in 1920 because of silicosis epidemia in Virginia... General rules about disability and compensation system was revised for the whole the USA in 1978.... The system is“no fault” • FRANCE: • Disability and compensation system began in 1919… • The system is “Occupational Diseases List” Eur Respir J 1994; 7: 969-80

  12. Legally; USA: - Spirometry ...main test, Exercise test when necassary France: - Spirometry and ABG “first line” test - DLCO and ABG “second line” test - Exercise test and right heart cateterization when necassary England: -Clinical, X-Ray(by at least 2 reader according to ILO classification), PFTs Canada: - Primer physician sends the patient to disability office: -Spirometry and x-ray main test - Exercise test and another tests when necassary NHLBI Workshop Summary - Am Rev Respi Dis 1988; 137:1505-1510

  13. ILO: - Clinic-spirometry-DLCO-Volumes-...Exercise test... WHO-1970 - VO2max < 2 METS( 7 ml/kg/min)handicap SWEDEN: -Impairementspirometry and ABG -Disability....Exercise tests(Ergospirometry/6-12 min. walking test) -Handicap...evaluating work, social, envirionmental and psychological factors NHLBI Workshop Summary - Am Rev Respi Dis 1988; 137:1505-1510

  14. In Turkey ?

  15. Disability and compensation system • began at 1946 because of pnomoconiosis... • -In 1965circular • -In 1972 regulated…This system • had been revised few times, • in addition is still used by SSS.

  16. General view of Disability term ?

  17. UK Social Security 1975 -Loss of faculty - Disability - Disablement ATS-1986 AMA-2000 -Impairment - Diasbility WHO 1980 -2001 - Dispne - İmpairment - Disability - Handicap - Sunjective - Objective - Preexisting - Coexisting - Organic impairment - Functional impairment - Permanent partial disability - Permanent total disability - Temporary disability

  18. Impairment Disability Handicap Malingering

  19. Malingering-Distinguishing from reality… • Conflicts between patiet’s answers... • Cooperation to PFTs... • Coordination to independent effort tests: such as FRC • Exercise test…

  20. Impairment Handicap Diseases, Injury, Situation Disability Patient...Physician...Patient’s relatives...Insuruance WHO-1980-2001

  21. Disability of Respiratory Diseases: • General-Specific Situations • National-International Social Security Administrations

  22. COPD Social Security Disability-1992

  23. Restrictive Lung Diseases Social Security Disability-1992

  24. ABG Social Security Disability-1992

  25. Chronic bronchitis Veterans Administration-1991

  26. Asthma Veterans Administration-1991

  27. After the disability decision, depending on disability rate, • the person is being granted for some rights . • -The physician must not be influenced by neither patient • nor by the insuruance. • In order to be independent, some of the medical organizations have • determined some rules according to guideliness for disabitiy • evaluations. • Canadian Medical Assoc....1979 • ATS...1982-1986 • AMA...1993...2000 • European Society for Clinical Respiratory Physiology...1990 • Brazilian Thorasic Soc...1998

  28. Category-1 No function lost (0%) Category-2 Mild Function lost (10-15%) Category-3 Moderate Function lost (30-45%) Category-4 Heavy Function lost (50-100%) FVC(%) > 80 and 60-79 or 51-59 or < 50 or FEV1(%) > 80 and 60-79 or 41-59 or < 40 or FEV1/FVC > 75 and 60-74(69) 41-59 or < 40 or DLCO(%) > 80 60-79 41-59 < 40 OR VO2max (ml/kg/min) (%) METS 25 70 7.1 20-25 60-69 5.7-7.1 15-20 40-59 4.3-5.7 < 15 < 40 < 4.3 General disability evaluation by functional parameters ATS-1986, AMA-2000

  29. ABG analysis is not necessarly used rutinly for • disability evaluation, but if there is a suspicion • between clinical and PFTs parameters ABG • analysis should be used… • But must be careful ! ATS-1986

  30. Algorithm of Respiratory Disability Evaluation Request FEV1 < 40% FVC < 50% FEV1/FVC < 40% 1. Step NO YES 2. Step DLCO < 40% handicap NO 3. Step Work change? Exercise VO2 max < 15 ml/kg/min < % 40 METS < 4.3 4. Step NO ATS/ 1982-1986

  31. Nonoccupational respiratory diseases-disability In Turkey SSS Severe restrictive/obstructive or combined PTFs defects SSS-1985

  32. Disability of special situations -Bronchial Asthma -ILD-Pnomoconiosis-Lung cancers

  33. Disability degree Findings 10% -Mild 1-2 attacks per year, no clinical findings between attacks. 30% – Moderate 1-2 per month, and dyspnea during exercise 60% – Heavy >1 attacks per week, dyspnea 100% - Severe Almost one attack each day, dyspnea during rest, weight lose, general health problems, etc. Asthma-Disability Veterans Administration-1991; Clin Chest Med 1997; 18: 471-82

  34. In spite of all the treatments, PFTs show that irreversible heavy obstructive defect.(Category-4) Also frequency of attacks affect the rate of disability. AMA-1993

  35. Asthma Re-evaluate the treatment Insufficient Sufficient • Temporary disability evaluation • (functional) • -Work change • -Follow up treatment • Periodically patient control • At least 2 years change of work • Permanent disability evaluation • Comorbidite Follow up AMA-1993

  36. SCORE FEV1 (%) 0 > 80 1 70-80 2 60-69 3 50-59 4 <50 I. After BD FEV1 ATS-1993

  37. SCORE Change % FEV1 PC20 mg/ml 0 < 10 > 8 1 10-19 8-0.5 2 20-29 0.5-0.125 3 > 30 < 0.125 II. Reversibility or BPT ATS-1993

  38. SCORE Treatment 0 None 1 Rare BD and/or Cromoline 2 Daily BD and/or Cromoline –low dose inhale steroide(<800 microgr BM or equivalence) 3 Continue BD + high dose inhale steroide(>800 BM or equivalence or 1-3 per year oral/IV steroide) 4 Continue BD + inhale (>1000 mg) and daily oral /IV steroide III. Necessary Treatment ATS-1993

  39. Degree Total Score 0 0 I 1-3 II 4-6 III 7-9 IV 10-11 Uncontrolled asthma in spite of maximum treatment IV. Degree of Disease ATS-1993

  40. Degree Total score Disability Rate 0 0 No effects I 1-3 No Disability II 4-6 Mild (10-25%) III 7-9 Moderate (26-50%) IV 10-11 Heavy (51-66%) V > 11 Severe (>67%) Disability Rate According to Severity of Disease ATS-1993

  41. If it is not occupational, general disability rules • applied: • - SSS... If PTFs severly effected Handicap • - Other insuruance disability rate related to • PFTs findings : 20-40-80 % • -If it is occupational, disability rate related to • PFTs findings Asthma

  42. no. Findings Rate 1 PFTs findings: obstructive/ restrictive/ combined a- Mild b- Moderate c- Heavy 6 30 57 Table-A. List#4 Respiratory Diseases: (Except Pnomoconiosis) SSS-Disability Guidelines-1985

  43. PNOMOCONIOSIS...

  44. Pnomoconiosis Veterans Administration-1991

  45. PFTs defect’s level is accepted for disability evaluation of pnomoconiosis...

  46. Category-1 No function lost (0%) Category-2 Mild Function lost (10-15%) Category-3 Moderate Function lost (30-45%) Category-4 Heavy Function lost (50-100%) FVC(%) > 80 and 60-79 or 51-59 or < 50 or FEV1(%) > 80 and 60-79 or 41-59 or < 40 or FEV1/FVC > 75 and 60-74(69) 41-59 or < 40 or DLCO(%) > 80 60-79 41-59 < 40 OR VO2max (ml/kg/min (%) METS 25 70 7.1 20-25 60-69 5.7-7.1 15-20 40-59 4.3-5.7 < 15 < 40 < 4.3 General disability evaluation by functional parameters

  47. PNOMOCONIOSIS - DISABILITY * X-Ray Findings are essential (objective ???)... * Clinicaland funtional findings???... *Conflicts when same pathologie and same diagnosis applied to “A-B-C-D-E” table and the results differ. Because of : - Different job - Age * Decimal disability rates: such as 10.3% !!! * Fibrogenic and nonfibrogenic pnomoconiosis have same criteria… SSS-Disability Guidelines-1985

  48. X±SD Age 50±5 Number of working days in Turkey 2018±980 Number of working days in Germany 2591±1209 Calculated disability rate in Turkey (%) 33.9±15.7** Calculated disability rate in Germany (%) 16.9±18.3** Disability evaluation of Pnomoconiosis(The difference between Germany and Turkey)* *n: 54 **p < 0.001 Akkurt İ, ve ark. Differences in disability evaluation between differentcountries. Eur Respir J 1997(Suppl 23):263s

  49. GERMANY TURKEY r p r p X-Ray Profusion Score 0.038 >0.05 +0.745 0.001 PFTs degree +0.974 <0.001 0.049 >0.05 Disability rate of other country 0.042 >0.05 0.042 >0.05 Disability evaluation of Pnomoconiosis(The difference between Germany and Turkey)* Akkurt İ, ve ark. Differences in disability evaluation between differentcountries. Eur Respir J 1997(Suppl 23):263s

  50. The factors that influenced survive of workers who were disabled from CWP and Silicosis Disabled and then dead CWP and silicosis cases (n:29): survive years was significantly negative correlated with initial PFTs findings r: - 0.851, p < 0.005 Akkurt İ ve ark. Toplum ve Hekim 1997; 12(77): 17-21

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