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, MDCumhuriyet University Medical School

Dept. of Chest Diseases SİVAS-TURKEY

Topics1. Questions... Problems... Cases...2. Historical approach3. General approach to “disability

evaluation”4. General and specific situations5. TTS Guidelines of Respiratory Diseases Disability

Evaluation

6. Conclusions and suggestions…

* 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

* 1992- SSS AODH : Pnomoconiosis Disability* 1994- SSS Ank.Teaching Hospital: Disability ???

- Akkurt İ ve ark. Akciğer hastalıklarında maluliyet sorunu.Tüberküloz ve Toraks 1995; 43(3): 172-83

- Akkurt İ. MeslekHastalıkları Hastanelerine işlerlik kazandırılması 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 Silikosisli kişilerde yaşam süresini etkileyen faktörler. Toplum ve Hekim 1997;12(77):17-21

-Akkurt İ ve ark. Pnömokonyozda maluliyet değerlendirmesi(Almanya ile Türkiye arasında farklılıklar). Solunum Hastalıkları 1998;9(4):745-52

-Karadağ ÖK, Akkurt İ, 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 çözüm önerileri.Toplum ve Hekim 1998;13(3):191-5

-Akkurt İ. 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

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

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...

TTS :

-Disability…30-45%

Pension Fundation:

-Disability....40%

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 examinationNormal, PFTsNormal

• BPT positive(PC20: 0.125mg/ml)• PEFmeters positive Occupational

asthma

Case-2: Occupational asthmaDecision: 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%

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

Historical process...

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

NHLBI Workshop Summary - Am Rev Respi Dis 1988; 137:1505-1510

USA:- Spirometry ...main test, Exercise test when necassary

Legally;

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

ILO:- Clinic-spirometry-DLCO-Volumes-...Exercise test...

SWEDEN:-Impairementspirometry and ABG-Disability....Exercise tests(Ergospirometry/6-12 min. walking test)-Handicap...evaluating work, social, envirionmental and psychological factors

WHO-1970- VO2max < 2 METS( 7 ml/kg/min)handicap

In Turkey

?

-Disability and compensation system began at 1946 because of pnomoconiosis...

-In 1965circular-In 1972 regulated…This system had been revised few times, in addition is still used by SSS.

General view of Disability term

?

WHO 1980 -2001

- Dispne- İmpairment- Disability- Handicap- Sunjective- Objective- Preexisting- Coexisting- Organic impairment- Functional impairment- Permanent partial disability- Permanent total disability- Temporary disability

UK Social Security 1975

-Loss of faculty- Disability- Disablement

ATS-1986AMA-2000-Impairment- Diasbility

Impairment

Disability

Handicap

Malingering

Malingering-Distinguishing from reality…

• Conflicts between patiet’s answers...• Cooperation to PFTs...• Coordination to independent effort

tests: such as FRC• Exercise test…

Diseases, Injury,Situation

Impairment Disability Handicap

WHO-1980-2001

Patient...Physician...Patient’s relatives...Insuruance

Disability of Respiratory Diseases: General-Specific Situations

National-International

Social Security Administrations

COPDHeight(cm) FEV1(L)< MVV(L/dk)<

< 152.4 1.0 40 155-160 1.1 44 162-165 1.2 48 168-170 1.3 52 172-175 1.4 56 177-180 1.5 60

>182 1.6 64

Social Security Disability-1992

Restrictive Lung DiseasesHeight(cm) VC(L)<

< 152.4 1.2 155-160 1.3 162-165 1.4 168-170 1.5 172-175 1.6 177-180 1.7

>182 1.8

Social Security Disability-1992

ABG<3000 feet(<915 m)

3000-5000 f(915-1515m)

>6000 f(>1800m)

PaCO2 PaO2 PaCO2 PaO2 PaCO2 PaO2<30 <65 <30 <60 <30 <5531 64 31 59 31 5432 63 32 58 32 5333 62 33 57 33 5234 61 34 56 34 51>40 55 >40 50 >40 45

Social Security Disability-1992

Chronic bronchitisLevel Findings Rate

Severe Dispnea during rest, productive cough, heavy obstructive PFTs, right heart insufficiency findings.

100

Heavy Dispnea during mild exercise, productive cough, heavy obstructive PFT

60

Moderate severe

Productive cough, dispnea during exercise, rales on physical examination, obstructive PFT.

30

Moderate Cough, dispnea, bilaterally rales 10

Mild Cough 0

Veterans Administration-1991

AsthmaSevere Frequent asthma attacks, severly dyspnea

between attacks, and because of lost of too much weight, general health situation very serious.

100

Heavy At least one attack per week, dyspnea between attacks, can not work because of dyspnea

60

Moderate 1-2 attacks per month, dyspnea during heavy exercise

30

Mild 1-2 attacks per year 10

Veterans Administration-1991

-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

General disability evaluation by functional parameters

< 15< 40 < 4.3

15-2040-594.3-5.7

20-2560-695.7-7.1

25707.1

VO2max(ml/kg/min)(%)METS

OR < 4041-5960-79 > 80DLCO(%) < 40 or41-59 or60-74(69) > 75 andFEV1/FVC < 40 or41-59 or60-79 or> 80 andFEV1(%) < 50 or51-59 or60-79 or> 80 andFVC(%)

Category-4 Heavy Function lost (50-100%)

Category-3 Moderate Function lost (30-45%)

Category-2 Mild Function lost (10-15%)

Category-1 No function lost (0%)

ATS-1986, AMA-2000

-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

Algorithm of Respiratory Disability Evaluation

Request FEV1 < 40%FVC < 50%

FEV1/FVC < 40%

YES

handicap

NO

DLCO < 40%

NO

ExerciseVO2 max < 15 ml/kg/min

< % 40 METS < 4.3

NOWork

change?

1. Step

2. Step

3. Step4. Step

ATS/ 1982-1986

Severe restrictive/obstructive or combined PTFs defects

Nonoccupational respiratory diseases-disability

SSS-1985

In TurkeySSS

Disability of special situations

-Bronchial Asthma -ILD -Pnomoconiosis-Lung cancers

Asthma-Disability

Almost one attack each day, dyspnea during rest, weight lose, general health problems, etc.

100% - Severe

>1 attacks per week, dyspnea60% – Heavy

1-2 per month, and dyspnea during exercise

30% – Moderate

1-2 attacks per year, no clinical findings between attacks.

10% -Mild

FindingsDisability degree

Veterans Administration-1991; Clin Chest Med 1997; 18: 471-82

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

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

I. After BD FEV1

<504

50-593

60-692

70-801

> 800

FEV1 (%)SCORE

ATS-1993

II. Reversibility or BPT

ATS-1993

< 0.125> 303

0.5-0.12520-292

8-0.510-191

> 8< 100

PC20 mg/ml

Change % FEV1 SCORE

III. Necessary Treatment

Continue BD + inhale (>1000 mg) and daily oral /IV steroide

4

Continue BD + high dose inhale steroide(>800 BM or equivalence or 1-3 per year oral/IV steroide)3

Daily BD and/or Cromoline –low dose inhale steroide(<800 microgr BM or equivalence)2

Rare BD and/or Cromoline1

None0

TreatmentSCORE

ATS-1993

IV. Degree of Disease

Uncontrolled asthma in spite of maximum treatment

10-11IV

7-9III

4-6II

1-3I

00

Total ScoreDegree

ATS-1993

Disability Rate According to Severity of Disease

ATS-1993

Severe (>67%)> 11V

Heavy (51-66%)10-11IV

Moderate (26-50%)7-9III

Mild (10-25%)4-6II

No Disability1-3I

No effects00

Disability RateTotal scoreDegree

Asthma

-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

Table-A. List#4 Respiratory Diseases: (Except Pnomoconiosis)

63057

PFTs findings: obstructive/restrictive/combined

a- Mild b- Moderate c- Heavy

1

RateFindingsno.

SSS-Disability Guidelines-1985

PNOMOCONIOSIS...

PnomoconiosisSevere On x-ray extensive lesions such as lesions of

Pulmonary TB, or severe PFTs findings, dyspnea at rest and general health weakness

100

Heavy Diffuse fibrosis, general health weakness, heavy PFTs findings, heavy dyspnea during mild exercise

60

Moderate Significant pulmonary fibrosis, moderate dyspnea during mild exercise, moderate PFTs defect

30

Mild Symptomatic because of mild pulmonary fibrosis

10

Veterans Administration-1991

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

General disability evaluation by functional parameters

< 15< 40 < 4.3

15-2040-594.3-5.7

20-2560-695.7-7.1

25707.1

VO2max(ml/kg/min(%)METS

OR < 4041-5960-79 > 80DLCO(%) < 40 or41-59 or60-74(69) > 75 andFEV1/FVC < 40 or41-59 or60-79 or> 80 andFEV1(%) < 50 or51-59 or60-79 or> 80 andFVC(%)

Category-4 Heavy Function lost (50-100%)

Category-3 Moderate Function lost (30-45%)

Category-2 Mild Function lost (10-15%)

Category-1 No function lost (0%)

PNOMOCONIOSIS - DISABILITY

* X-Ray Findings are essential (objective ???)...* Clinical and 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

Disability evaluation of Pnomoconiosis(The difference between Germany and Turkey)*

16.9±18.3**Calculated disability rate in Germany (%)

33.9±15.7**Calculated disability rate in Turkey (%)

2591±1209Number of working days in Germany

2018±980Number of working days in Turkey

50±5Age

X±SD

**p < 0.001

Akkurt İ, ve ark. Differences in disability evaluation between different countries. Eur Respir J 1997(Suppl 23):263s

*n: 54

Disability evaluation of Pnomoconiosis(The difference between Germany and Turkey)*

>0.050.042>0.050.042Disability rate of other country

>0.050.049<0.001+0.974PFTs degree

0.001+0.745>0.050.038X-Ray Profusion Score

prpr

TURKEYGERMANY

Akkurt İ, ve ark. Differences in disability evaluation between different countries. Eur Respir J 1997(Suppl 23):263s

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

Disability evaluation criteria of Pnomoconiosis

TTS-Disability Evaluation Guideliness

Clinic X-Ray Functional Findings*

Disability rate

No Symptoms ILO category 1/0 Normal No-0%Dyspnea during heavy effort

Minimal Pulmonary fibrosis (ILO: 1/1, ½)

Normal Mild10 %

Dyspnea during moderate effort

Clear pulmonary fibrosis (ILO: 2/1, 2/2,2/3)

Mild Moderate20-40%

Dyspnea during mild effort, general health weakness

Diffused pulmonary fibrosis (ILO: 3/2, 3/3, 3/+ or A opacite)

Moderate Heavy50-70%

Dyspnea during rest, opportunist infection, or general health weakness

B-C opacites Heavy Severe70-100%

* According to general functional assesment

Upper Respitory Obstructions:- CO2 retantion severe impairment...

OSA:- Sleepiness all day or- Chronic nocturnal hypoxemia… PHT- cor pulmonale… severe impairment...-According to PSG findings...

ATS/ 1982-1986-AMA200

ATS-1986

Control examinations

- Depend on disease and severty of disability...

COR PULMONALE- Handicap...

Exercise induced bronchospasm-If symptoms occured although all treatment,disability evaluation done according to PFTs findings ...

Where the this Guideline

ComeFrom

???

TTS- Working group of Environmental and Occupational Diseases:

-09 May1998, Antalya: “Our Working group must prepare –

Guidelines of Respiratory Diseases Disability Evaluation”...

- 13 April 1999, Istanbul : Preliminary darft must be sent to

presidents of another working groups...

GUDELINES OF RESPIRATORY DISEASES DISABILITY

EVALUATION ( Preliminary Draft and Appendix )

TURKISH THORACIC SOCIETYENVIRONMENTAL AND OCCUPATIONAL

DISEASE WORKING GROUPApril-2000

September 2005

- Did not use any countries’ social security admn.’s guide...

- Used International Independent Medical Associations’ Guide...

- Chest Diseases Specialists...

EVALUATION PROTOCOL1. What insurance wants?2.Anamnesis: Personal, environmental, and occupotional3.Physical examination4.Laboratory tests

   Ekstrapulmonary tests : Standard biochemistry, Hemogram, and ECG

   Pulmonary tests: x-ray, Spirometry, DLCO, ABG analysis(if necessary), Ergospirometry(if necessary)

5. Diagnosis6. Comment:

   Pathology related to occupation ?   Pathology temporary or permanent ?   Need to work change ?   Treatment and prognosis ?

GENERAL EVALUATION CRITERIAS

General disability evaluation by functional parameters

< 15< 40 < 4.3

15-2040-594.3-5.7

20-2560-695.7-7.1

25707.1

VO2max(ml/kg/min(%)METS

OR < 4041-5960-79 > 80DLCO(%) < 40 or41-59 or60-74(69) > 75 andFEV1/FVC < 40 or41-59 or60-79 or> 80 andFEV1(%) < 50 or51-59 or60-79 or> 80 andFVC(%)

Category-4 Heavy Function lost (50-100%)

Category-3 Moderate Function lost (30-45%)

Category-2 Mild Function lost (10-15%)

Category-1 No function lost (0%)

ATS-1986, AMA-2000

Algorithm of Respiratory Disability Evaluation

Request FEV1 < 40%FVC < 50%

FEV1/FVC < 40%

YES

handicap

NO

DLCO < 40%

NO

ExerciseVO2 max < 15 ml/kg/min

< % 40 METS < 4.3

NOWork

change?

1. Step

2. Step

3. Step4. Step

ATS/ 1982-1986

In some situations, oxygen consumption and needed energy

L/min.ml/kg/min.

3.91.0213.6Making Bed

3.60.9512.6Bathing

3.00.7810.4Walking

2.20.587.7Dressing

1.50.405.3Sitting

1.00.253.5Sleeping

METSVO2Situations

Disability of special situations

- Bronchial Asthma - ILD - Pnomoconiosis- Lung cancers

I. After BD FEV1

<504

50-593

60-692

70-801

> 800

FEV1 (%)SCORE

ATS-1993

II. Reversibility or BPT

ATS-1993

< 0.125> 303

0.5-0.12520-292

8-0.510-191

> 8< 100

PC20 mg/ml

Change % FEV1 SCORE

III. Necassary Treatment

Continue BD + inhale (>1000 mg) and daily oral /IV steroide

4

Continue BD + high dose inhale steroide(>800 BM or equivalence or 1-3 per year oral/IV steroide)3

Daily BD and/or Cromoline –low dose inhale steroide(<800 microgr BM or equivalence)2

Rare BD and/or Cromoline1

None0

TreatmentSCORE

ATS-1993

IV. Degree of Disease

Uncontrolled asthma in spite of maximum treatment

10-11IV

7-9III

4-6II

1-3I

00

Total ScoreDegree

ATS-1993

Disability Rate According to Severity of Disease

ATS-1993

Severe (>67%)> 11V

Heavy (51-66%)10-11IV

Moderate (26-50%)7-9III

Mild (10-25%)4-6II

No Disability1-3I

No effects00

Disability RateTotal scoreDegree

Disability evaluation criteria of Pnomoconiosis

TTS-Disability Evaluation Guideliness

Clinic X-Ray Functional Findings*

Disability rate

No Symptoms ILO categori 1/0 Normal No-0%Dyspnea during heavy effort

Minimal Pulmonary fibrosis (ILO: 1/1, ½)

Normal Mild10 %

Dyspnea during moderate effort

Clear pulmonary fibrosis (ILO: 2/1, 2/2,2/3)

Mild Moderate20-40%

Dyspnea during mild effort, general health weakness

Diffused pulmonary fibrosis (ILO: 3/2, 3/3, 3/+ or A opacite)

Moderate Heavy50-70%

Dyspnea during rest, opportunist infection, or general health weakness

B-C opacites Heavy Severe70-100%

* According to general functional assesment

ILD-Last disability evaluation must be done 6 months afterfrom initial diagnosis…Functional criteria

Lung ca

- Person should be considered handicap at initial definitive diagnosis…

- 1 year later control examination if there are any findings related to diagnosed diseasehandicap continues

- No findings…re-evaluate according to PFTs defect

At the daily practice, unfortunately, disability evaluation could be inevitable…

TTSGuideliness of Respiratory Disesases Disability Evaluation

CONCLUSION…

THANKS…