http://informahealthcare.com/jas ISSN: 0277-0903 (print), 1532-4303 (electronic) J Asthma, Early Online: 1–9 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/02770903.2014.971966

ORIGINAL ARTICLE

The use of a work-related asthma screening questionnaire in a primary care asthma program: an intervention trial Katie R. Killorn, MSc1,2, Suzanne M. Dostaler, MSc1,2, Patti A. Groome, PhD3, and M. Diane Lougheed, MD, MSc1,2,3 Asthma Research Unit, Kingston General Hospital, Ontario, Canada, 2Division of Respirology, Department of Medicine, Queen’s University, Ontario, Canada, and 3Department of Public Health Sciences, Queen’s University, Ontario, Canada

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Abstract

Keywords

Objectives: The work-related asthma screening questionnaire (long-version) (WRASQ(L)) is a 14-item tool designed to increase the recognition of work-related asthma (WRA) in primary care. The purpose of this study was to assess whether the WRASQ(L) provided additional information about a patient’s likelihood of WRA, beyond what was collected in standard care, and to assess the use of the WRASQ(L) in the primary care setting. Methods: This was an intervention study involving two Ontario primary care sites. Standard care for asthma patients in these sites involved completing the Asthma Care Map (ACM), a template for asthma management that includes seven WRA screening items. Participation in this study involved completing an electronic WRASQ(L) at each visit for participants and prompted care providers to record details related to WRA investigations. Ethics approval was obtained from an Institutional Review Board. Results: The study sample (N ¼ 37) was predominantly female (73.0%), with a mean age of 46.3 years (SD, 10.9). The use of WRASQ(L) identified additional work-related symptoms in 38% and exposures in 60% of participants over and above those identified by the ACM. Two participants were newly suspected of WRA during the study period. Conclusions: The WRASQ(L) provided added information about possible WRA over standard care. The use of the questionnaire’s results by care providers was limited due to barriers encountered in incorporating the use of electronic version of the WRASQ(L) into clinical practice. Once validated and implemented in practice, the WRASQ(L) has the potential to increase the recognition of WRA.

Detection, occupational asthma, prevention, work-aggravated asthma, work-exacerbated asthma

Introduction Approximately 25% of all adult asthma is associated with exposures in the work environment, which is termed workrelated asthma (WRA) [1]. WRA encompasses workexacerbated asthma (WEA), which is pre-existing asthma that is aggravated by the work environment, and occupational asthma (OA), which is adult-onset asthma caused by workplace exposures [1]. OA can be induced by sensitization to a specific substance at work, which is termed sensitizer-induced OA, or by exposure to an inhaled irritant at work, which is termed irritant-induced OA [1]. WRA is associated with negative health outcomes. Continued exposure to a causative agent in the workplace increases the risk of progressive deterioration in lung function [2]. Despite cessation of exposure, a substantial proportion of workers are left with permanent impairment, including respiratory symptoms, airway hyperresponsiveness, airway inflammation, and airway obstruction [3–6]. Timely diagnosis and early avoidance of further exposure increase the Correspondence: Dr. M. Diane Lougheed, Department of Medicine, Queen’s University, 102 Stuart Street, Kingston, Ontario K7L 2V6, Canada. Tel: +1613 548 2348. Fax: +1613 549 1459. E-mail: [email protected]

History Received 3 July 2014 Revised 27 August 2014 Accepted 27 September 2014 Published online 30 October 2014

likelihood of full recovery [7]. This literature is largely based on studies of OA. Similar findings of improvement with cessation have been found for WEA, but to a lesser extent [8,9]. WRA is under-recognized in the medical community despite the publication of practice guidelines [1,7,10]. Audits of medical charting in primary care reveal lack of documentation of both occupational and work-effect enquiries among cases of adult-onset asthma [11]. Even when it is recognized, there is a substantial duration of symptoms before the diagnosis of WRA, leading to increased morbidity [12–15]. Adults with asthma are predominantly cared for by their primary care physician. Family physicians and community respirologists report lack of expertise, time, and knowledge constraints as barriers to early recognition [16,17]. This group is in favor of templates for asking questions in history taking as a means to improve the detection of WRA [16]. Clinical history (unstructured and open interview) [18], specific questions addressed by physicians in the assessment of OA (structured interview) [19], and a patient-administered screening questionnaire for OA [20] have been validated in workers referred to the tertiary care setting for suspected OA. However, there is a need for a screening questionnaire to aid in the identification of individuals with possible WEA and/or

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Methods

Patient consent (informed and written) to participate in the study prompted: (i) participant self-administration of the electronic version of the WRASQ(L); and (ii) reminders for the educators to record the existence and the nature of relationships of asthma symptoms to the work environment, and details related to subsequent investigations. Such investigations were based on a management algorithm that was created with reference to the American College of Chest Physicians Consensus Statement for the assessment of suspected WRA [1] and are further described in the ‘outcome measures’ section to follow (secondary outcomes). Patient consent also authorized study personnel to collect information contained in their medical chart related to their asthma for up to 12 months after signing the consent form. Ethics approval for the study was obtained from an Institutional Review Board.

Study setting and design

Asthma care map and the WRASQ(L)

The Primary Care Asthma Program (PCAP) is an evidencebased [23] and outcome-based [24] asthma care program, implemented in 12 sites (funded by the Ministry of Health and Long-term Care) as well as 156 other primary care sites across Ontario. Each site has multiple primary care locations (family health teams, community health centers, nurse practitioner clinics, and solo physician practices). This program is mainly delivered by certified asthma/respiratory educators, referred to as ‘educators’ for the remainder of the report. These educators are health care professionals (nurses, respiratory therapists, or pharmacists) who have been certified by the Canadian Network for Respiratory Care through a national examination. The Ontario Lung Association’s Asthma Care Map (ACM) is a template for asthma management based on the current Canadian Thoracic Society’s Asthma Guidelines [23]. Standard practice at PCAP sites involves the care provider completing the ACM at each education visit with the patient. There are currently seven WRA screening items on the ACM. A short-version of the WRA screening questionnaire was originally created to supplement these WRA screening items. The long-version (WRASQ(L)) (Figure 1) was created as a ‘stand-alone’ version for primary care sites, which did not employ the ACM (non-PCAP sites), and was used as the intervention is this study. This study was a prospective intervention trial involving two sites. Both sites were of comparable urban/rural status and proximity to tertiary care providers. Site one comprised of eight locations with two educators. Seven of these locations were family health teams (PCAP locations). The eighth location was an asthma education center located within a hospital which received patients referred from both primary care providers and specialists. Site two was comprised of 19 PCAP locations, with seven educators. Patients were eligible if they were English-speaking, of working age (18–65 years), and had doctor-diagnosed asthma (confirmed using objective measures, or suspected). The only exclusion criterion was a confirmed diagnosis of chronic obstructive pulmonary disease. Consecutive patients from each site’s roster of adult asthma patients were invited to participate at their regularly scheduled asthma-education visit. Recruitment was conducted by the educators, but was facilitated by a research assistant (KRK) at Site one.

Both the ACM and the WRASQ(L) are based on three concepts: occupation, relationship of asthma symptoms to work, and workplace exposures (Table 1). Generally, ACM data elements are consistently defined across each site’s electronic charting tool. An exception is the exposure response categories, which were developed to reflect exposures associated with WRA and differ depending on the site’s development method. The exposure item on the ACM is generally meant to capture current workplace exposures, but at Site one, the text note option was sometimes used to report past exposures if deemed relevant by the educator.

OA in primary care [21]. In 2009, the work-related asthma screening questionnaire (long-version) (WRASQ(L)) was developed by an expert advisory committee after a literature review [22]. The WRASQ(L) is a 14-item, self-administered tool designed to increase the detection of WRA in primary care by prompting a detailed history of employment, inhalation exposures, and the relation between asthma symptoms and work. This tool was found to have good test re-test reliability, content, and face validity, as well as low respondent burden [22]. The purpose of the current study was to assess whether the WRASQ(L) provided additional information on a patient’s likelihood of WRA, beyond what was collected in standard care, and to assess the use of the WRASQ(L) in the primary care setting.

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Outcome measures The outcome measures of this study were related to the clinical actions of the educators. The primary outcome was the number of newly suspected WRA cases detected within the study period. The secondary outcomes recorded for those with newly suspected WRA included the number the educator suggested for referral to a specialist due to suspicion of WRA; the number with whom the educator discussed whether it was advisable to remain at current job until diagnostic tests were performed to allow confirmation or exclusion of diagnosis of WRA; the number to whom the educator provided a peak flow meter and diary; and the number with whom the educator discussed the option of a compensation claim. Data collection The electronic version of the ACM was completed using each site’s respective medical electronic charting system. An electronic study portal (web access) called the AsthmaLifeÕ (Queen’s University, Kingston) was used as a means to collect data elements not currently captured in the ACM. The patient portal of AsthmaLifeÕ was used to house the WRASQ(L). The provider portal allowed educators to view the participant’s WRASQ(L), record information relevant to both WRA suspicion and subsequent clinical investigations. Planned study workflow dictated that recruitment and WRASQ(L) administration would occur during the education visit. This provided an opportunity for the educator to view

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DOI: 10.3109/02770903.2014.971966

Figure 1. The work-related asthma screening questionnaire (long-version) (WRASQ(L)).

the participant’s WRASQ(L), and then proceed to record details related to their suspicion of WRA and subsequent clinical investigations, all with the participant available for discussion. Viewing of the WRASQ(L) was tracked electronically. Due to time constraints at Site one, the research assistant recruited participants and administered the WRASQ(L) after the education visit. This meant that the educator had to review the participant’s WRASQ(L) and record details related to suspicion of WRA and investigations at a separate occasion, typically over the phone with the participant.

Analysis strategies Univariate analyses were conducted to describe sample characteristics, WRASQ(L) responses, and the frequency of clinical action outcomes. The WRASQ(L) was assessed for the ability of its four additional symptom items and its two workplace exposure items to collect additional information on the likelihood of WRA that was not collected on the ACM. First, McNemar’s Test was computed for pairs of participant responses to symptom items on the WRASQ(L) and the ACM (any affirmative response to a symptom item on the

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Figure 1. Continued.

WRASQ(L) vs. any affirmative response to a symptom item on the ACM). Then, McNemar’s Test was computed separately for each additional symptom item on the WRASQ(L) (vs. any affirmative response to a symptom item on the ACM), to identify sources of new information. In this analysis, missing responses were considered as non-affirmative responses. A similar procedure was conducted for exposure items on the WRASQ(L) and ACM; however, this was done separately for Sites one and two due to their different exposure response categories on the ACM. A significance level (a) of 0.05 was set. All statistical analyses were conducted using SASÕ (Version 9.3, SAS Inc., Cary, NC).

Results Study sample characteristics and recruitment figures The final study sample size was 37 (Site one, n ¼ 30; Site two, n ¼ 7). Table 2 presents the demographic and clinical characteristics of the study sample. In terms of recruitment, this sample size represents the number of participants who consented to participate, out of the entire population of adult (18–65 years) asthma patients cared for at participating PCAP sites during the study period (n ¼ 344). The study sample (n ¼ 37) had similar age and gender distributions as the larger patient population (n ¼ 344; female: n (%), 244 (70.9); age:

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Table 1. A Comparison of Items on the ACM and the WRASQ(L). Standard practice (ACM)

WRASQ(L)

Occupation items Item 1 Item 2 Item 3 Symptom items Started at work Item 4 Starting within days of an accidental spill or fire Item 5 Worsened at work Item 6 Item 7 Item 8 Item 9 Item 10 Different (less) on days off Item 11 Different (less) on holidays Exposure items Item 12 Occupational work exposure(s) Item 13 (Site one: 31 categories + option for text note; Site two: 12 categories) Item 14

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Occupation

Table 2. Study sample characteristics.

Current occupation/industry Past occupation(s) Employment status Start at work Start in the days of a spill or fire at work Worsen at work Worsen on your first day back to work Worsen during the work day Worsen at home after work Worsen throughout the workweek Different (less) on days off work and/or holidays Current work exposures (22 categories) Past work exposures (22 categories) Protective measures

Table 3. Work-related asthma symptom results.

N ¼ 37

n

Mean (SD)

Median (range)

WRASQ(L) items 4–11 (N ¼ 37)

Age, years BMI, kg/m2 Age at diagnosis, years

37 34 22

46.2 (10.9) 29.0 (7.2) 38.0 (18.6)

47.7 (21–63) 28.0 (18.8–48.1) 43.0 (1–60)

N ¼ 37

n

Categories

%

Gender Asthma diagnosis

37 37

Smoking status

35

Education

24

Female Confirmed Suspected Non-smoker (life-long) Ex-smoker Current smoker Less than or some high school High school graduate Any post-secondary 520 000 20 000–39 000 40 000–59 000 60 000–79 000 80 000+ Prefer not to say

73.0 54.1 45.9 51.4 31.4 17.1 12.5

Any asthma Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11

Household income, $

22

20.8 66.7 13.6 13.6 18.2 4.5 27.3 22.7

mean (SD), 46.3 (12.5)). The number of those patients who declined after invitation to participate was not recorded. Of the 17 participants with a ‘suspected’ diagnosis of asthma, follow-up data indicate that the diagnosis was eventually confirmed in three participants and excluded in two participants.

symptom item Start at work Start in the days of a spill or fire at work Worsen at work Worsen on your first day back to work Worsen during the work day Worsen at home after work Worsen throughout the workweek Different (less) on days off work and/or holidays

% 51.4 18.9 0 32.4 21.6 37.8 16.2 24.3 32.4

The average number of years spent at current occupation was 9.1 (SD, 9.8; range 0–39). A mean of 4.0 current workplace exposures (SD, 3.2; range 0–14) and a mean of 5.1 past workplace exposures (SD, 4.5; range 0–15) were reported. Cold air (43.2%), cleaning agents (51.4%), and dusts (64.9%) were the most frequently reported current workplace exposures, while cold air (48.6%), chemicals (51.4%), dusts (62.2%), and cleaning agents (70.3%) were the most frequently reported past workplace exposures. Seventeen participants reported the use of protective measures at their workplace. Table 3 presents the descriptive WRASQ(L) symptom results. Approximately half (51.4%) of the participants responded affirmatively to at least one of the eight WRA symptom questions, and the frequency of positive responses to individual questions ranged from 0 to 37.8%. ACM vs. WRASQ(L)

Descriptive WRASQ(L) results All 10 occupation categories in the Statistics Canada National Occupation Classification for Statistics (NOC-S 2006) [25] were represented in past occupations, while ‘primary industry’ was the only category not represented in current occupations. Forty-six percent of participants were employed full time, 10.8% were employed part-time, 2.7% performed shift-work, and 40.5% reported ‘other’ employment status.

Fourteen participants (37.8%) reported at least one workrelated symptom on the WRASQ(L) and none on the ACM (p ¼ 0.03) (Table 4). The ‘worsen during the work day’ item (item 8) identified an additional work-related symptom in the highest number of participants of the four additional symptom items present on the WRASQ(L) (n ¼ 10; p ¼ 0.30). Among those 10, three also answered affirmatively to the ‘worsen on your first day back to work’ item (item 7), five answered

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Table 4. Work-related symptom information provided by the WRASQ(L) vs. work-related symptom information provided by the ACM. ACM Any symptom N Y WRASQ(L)

Any symptom (items 4–11)

Additional items not in the ACM

7. Worsen on your first day back to work 8. Worsen during the work day 9. Worsen at home after work 10. Worsen throughout the workweek

Total

p Valuea 0.03

N Y N Y N Y N Y N Y

14 14 24 4 18 10 22 6 23 5

4 5 5 4 5 4 9 0 5 4

18 19 29 8 23 14 31 6 28 9

Total

28

9

37

1.00 0.30 0.61 1.00

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a

McNemar’s test for correlated proportions – exact test.

Table 5. Workplace exposure information provided by the WRASQ(L) vs. workplace exposure information provided by the ACM at Site one. ACM Any exposure, past or current N Y WRASQ(L)

Any exposure, past or current Any exposure, current Any exposure, past

Total

p Valuea 0.0001

N Y N Y N Y

3 17 4 16 7 13

1 9 2 8 1 9

4 26 6 24 8 22

Total

20

10

30

0.001 0.002

a

McNemar’s test for correlated proportions – exact test.

affirmatively to the ‘worsen at home after work’ item (item 9), and four answered affirmatively to the ‘worsen throughout workweek’ item (item 10). Items 7, 9, and 10 identified a work-related symptom in three additional participants over those identified in item 8 (one for each item). Four (10.8%) participants reported at least one work-related symptom on the ACM, and none on the WRASQ(L) (p ¼ 0.03). Since the symptom items on the ACM are also present on the WRASQ(L), this indicates inconsistency of responses. Results of the workplace exposure item comparison for Site one are presented in Table 5. At Site one, 17 participants reported at least one workplace exposure on the WRASQ(L) while they reported none on the ACM (p ¼ 0.0001). Sixteen of these 17 participants reported at least one current exposure on the WRASQ(L). For Site two, each of the seven participants reported at least one current and one past workplace exposure on the WRASQ(L), while two of the seven participants reported a workplace exposure on the ACM. A total of 22 participants (59.4%) (Site one, n ¼ 17; Site two, n ¼ 5) reported at least one workplace exposure on the WRASQ(L) while they reported none on the ACM.

Clinical actions of asthma educators Twenty-seven participants (Site one, n ¼ 25; Site two, n ¼ 2) had their WRASQ(L) viewed at least once by their educator. In relation to WRA suspicion, educators reported that three participants were confirmed, five were unknown, and three were suspected. Of the suspected cases, one was reported as such before the study period (in 1990). Two participants were newly suspected of WRA during the study period, both of whom had their WRASQ(L) viewed by their educator. In both cases, a peak flow meter/diary was provided by the educator and remaining at work until diagnostic tests were performed was discussed with the educator. There were no suggestions to refer to a specialist (under the suspicion of WRA); however, these two participants had been referred to asthma education by their respective respirologists. Further, one respirologist’s referral letter included note of a ‘suspected work-related component’. There were missing data on whether discussion of the compensation option had occurred with their educator. Follow-up data indicate that neither of these participants were formally diagnosed with WRA, but one participant was investigated by an occupational medicine specialist, and was labeled with a differential diagnosis of either WRA or irritable larynx syndrome.

DOI: 10.3109/02770903.2014.971966

Discussion Main findings The use of WRASQ(L) identified work-related symptoms and workplace exposures in 38% and 59% of participants, respectively, which were not identified in standard care. Only two participants were newly suspected cases of WRA during this study period, despite implementation of the WRASQ(L).

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Strengths and limitations The main strength of this study is its originality. To our knowledge, there is no existing screening questionnaire for both WEA and OA, designed specifically for the primary care setting. The results indicate that the WRASQ(L) provides substantial added information about the likelihood of possible WRA over standard care. Recruitment figures were lower than desired in the study resulting in a small sample size, which restricted the analyses we could conduct. This problem was likely related to educator time constraints. Introducing the study, gathering consent and facilitating the electronic questionnaire administration were often not feasible within the time frame of a busy education visit. Although Site one had the assistance of a research assistant, recruitment was limited to those with the extra time to stay after their visit. Other limitations stem from potential sources of measurement error in this study. Due to the fear of loss of work, patients may have been reluctant to report work-related symptoms and exposures to their educators. This measurement error is unlikely to differ from standard care (ACM) to the WRASQ(L) and, consequently, would not bias the comparison between the tools. Further, even if these figures are under-represented, there is still unmet need among the substantial number of participants who were willing to report symptoms and exposures. Second, educators may have been more inclined to record more detailed occupational histories or follow practice guidelines for the assessment of suspected WRA, since they were aware of the study, as per the ‘Hawthorne effect’ [26]. Third, participants may have over-reported the use of personal protective equipment on the WRASQ(L), which relates to ‘social desirability bias’ [27]. Interpretation of findings The sample was predominantly female, which is a characteristic of the adult asthma population in general [28], as well as asthma patients in primary care in Ontario [29]. The majority of participants were life-long non-smokers or ex-smokers and highly educated, which is comparable to other reports on attendees of outpatient asthma programs [30,31]. Further, there were similar gender and age distributions between the study sample and the entire population of adult asthma patients cared for at participating PCAP sites during the study period. While we must recognize the potential for selection bias given the low participation rate, this sample may be a representation of the larger population of primary care patients with asthma. Ideally, the WRASQ(L) was designed to be administered to patients with a confirmed diagnosis of asthma (using

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objective measures). In this study, 62.2% (n ¼ 23) of the participants met this standard. This figure is actually higher than what was found in a recent, large population-based study from Ontario (42.7% of all newly diagnosed individuals had received pulmonary function testing) [32]. Unfortunately, this is a reflection of the underutilization of objective measures and the gap between guideline-based recommendations and current practice. Four of the eight symptoms on the WRASQ(L) have been tested in validation studies of OA. Their sensitivities and specificities were calculated based on the data from the publications [18,19]. The items with the highest sensitivity in relation to OA were iterations of the ‘worsen at work’ (sensitivity, 90–91%; specificity, 9–14%) and ‘different (less) on days off work and/or holidays’ (sensitivity, 74–88%; specificity: 24–57%) items [18,19]. These items are already asked on the ACM. Of the four additional WRASQ(L) items, versions of the ‘worsen at home after work’ item were found to be fairly sensitive (sensitivity, 69%; specificity, 27– 46%), while an iteration of the ‘worsen throughout the workweek’ item was found to have a very low sensitivity (15%) and high specificity (84%) [18,19]. Not all symptom items have been validated in relation to sensitizer-induced OA, and to our knowledge, none of the symptom items have been formally validated against a diagnosis of WEA or irritant-induced OA. The WRASQ(L) was able to identify a substantial number of participants with a current or past workplace exposure who were not identified in standard care, which may be related to the form of delivery. Survey methods indicate that both the stem and the response categories are important sources of information to a respondent, particularly for those questions in which the respondent has not already formed a response [33]. In standard practice, the educators may have only asked the participants if they had any workplace exposure(s) (only ‘the stem’), without providing them with all the response categories. On the WRASQ(L), the participants may have produced a more considered response given they were presented with the question (‘the stem’) and the list of 22 workplace exposures (‘response categories’) with the option of answering yes/no to each. Validation studies may clarify whether this exposure list is too sensitive for screening purposes in primary care. Only two participants were newly suspected cases of WRA, and one of these cases may have been assigned suspicion based on the information in the specialist’s referral letter more so than information from the WRASQ(L). A likely explanation for this small number is that WRASQ(L) responses were not always viewed by educators, especially at Site two. This may be attributed to time constraints and the inconvenience of switching electronic interfaces (between the site’s standard medical electronic charting system and AsthmaLifeÕ ) to view the questionnaire during a visit. At Site one, WRASQ(L) viewing was often done at a separate occasion from the corresponding education visit. If they had been viewed within the visit, WRASQ(L) responses may have been discussed further or reflected upon for longer. Further, there was no instruction on how to interpret WRASQ(L) responses. Going forward, there may be a need to assist providers with the interpretation of this information.

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Summary of recommendations

References

We recommend that the WRASQ(L) continue to include multiple-response exposure items, and the symptom items should be assessed for sensitivity and specificity in relation to the diagnosis of both OA and WEA. In terms of the use of the WRASQ(L) in clinical practice, we recommend that the WRASQ(L) be completed by patients before or during an asthma visit, that responses be embedded in the standard medical electronic charting tool, and that review of those responses by the care provider be done during the visit. Electronic prompts should be included to alert the care provider of possible WRA. As a form of knowledge translation, this will assist the provider in providing care in accordance with best practices. Last, it is realistic to assume that the WRASQ(L) will be inadvertently administered to patients without a confirmed diagnosis of asthma (‘suspected’ cases). Although it is not ideal, administering this questionnaire in a preliminary assessment of asthma may be acceptable. The recommendation will always be to confirm the diagnosis of asthma before beginning the investigation of the WRA, as per the most recent expert consensus statement [1].

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Conclusions/key findings This study demonstrated that the WRASQ(L) provided additional information related to a patient’s likelihood of WRA that was not collected in standard care. However, the adoption of this questionnaire by the care provider in an education visit was limited due to time constraints and the burden of using an electronic study portal in addition to the standard electronic charting tool. Incorporation of the WRASQ(L) into the workflow of standard practice may increase recognition of possible WRA and prompt investigations. Future directions include evaluating the criterion validity (sensitivity and specificity) of the WRASQ(L) in relation to the diagnosis of both OA and WEA, through a prospective validation study.

Acknowledgements We would like to acknowledge Dr. Chris Licksai, Patti Moyse, Jessica Schooley, Madonna Ferrone, and all the site asthma educators for their contributions to this project.

Declaration of interest The authors alone are responsible for the content and writing of the paper. MDL has received research funding from the Government of Ontario, the Ontario Lung Association, MPEX Pharmaceuticals, Pharmaxis Ltd., AllerGen NCE Inc. (the Allergy, Genes and Environment Network), the Ontario Thoracic Society, the Canadian Cystic Fibrosis Foundation, Queen’s University, Glaxo Smith Kline Inc., Janssen Inc., and speaker honoraria from the Ontario Lung Association. The remaining authors report no conflicts of interest. This study was funded by AllerGen NCE Inc. (Grant number #09C3). K. R. K. was supported by the Senator Frank Carrel Fellowship, the R. S. McLaughlin Fellowship and a Queen’s Graduate Award, all from Queen’s University (Kingston, Ontario).

Work-related asthma screening questionnaire

DOI: 10.3109/02770903.2014.971966

J Asthma Downloaded from informahealthcare.com by Washington University Library on 12/29/14 For personal use only.

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The use of a work-related asthma screening questionnaire in a primary care asthma program: an intervention trial.

The work-related asthma screening questionnaire (long-version) (WRASQ(L)) is a 14-item tool designed to increase the recognition of work-related asthm...
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