MPM is relatively uncommon; hence, many clinicians may not appreciate the potential medicolegal implications of a diagnosis of MPM and may have little experience advising patients about this potentially compensable disease. The failure of clinicians to counsel patients with MPM about the possible occupational etiology of their disease and the potential for legal redress represents a missed opportunity to provide information that may have important financial consequences for patients and their families.
In the current study, we hypothesized that, in the course of managing patients with MPM, clinicians rarely educate patients about disease causation, rarely advise patients that they may have a compensable condition and rarely counsel their patients to pursue legal consultation. To test these hypotheses, we reviewed the medical records of patients newly diagnosed with MPM to: (1) assess the quality of occupational histories obtained from patients with a new diagnosis of MPM; (2) determine the quality of clinician counseling about the strong association between the development of MPM and occupational exposure to asbestos; (3) identify documentation of discussions with patients about the potential medicolegal implications of a diagnosis of MPM and (4) identify documentation of a recommendation to patients or family members to pursue legal consultation or to seek compensation for occupation-related MPM.
We conducted a structured retrospective analysis of the medical records of patients with a newly documented, pathologically confirmed, diagnosis of MPM to identify evidence of clinician counseling of patients regarding the potential causation of MPM and medicolegal implications of the disease, including possible compensation. We included patients with an International Classification of Diseases, ninth revision, Clinical Modification (ICD-9CM) Code for pleural malignancy (163) who, on chart review, were found to have pathologically confirmed MPM. We abstracted demographic data, occupational and environmental history and exposure data from records. We also reviewed the actions documented by healthcare providers based on their occupational and environmental history assessments and the diagnosis of MPM. The study was approved by the Stanford University Administrative Panel on Human Patients in Medical Research and the United States Department of Veterans Affairs Palo Alto Health Care System (VAPAHCS) Research and Development Committee.
Study Setting and Medical Record System
The study was conducted at VAPAHCS. VAPAHCS operates 3 hospital-based divisions with a total of 897 beds and 6 community-based outpatient clinics delivering health care to veterans of the U.S. military services. In FY 2007, VAPAHCS treated 56,654 patients. There were 8,435 inpatient discharges, and the average daily inpatient census, including nursing home patients, was 653. VAPAHCS uses an electronic health record system. All healthcare provider notes and virtually all other elements of patient medical records, including all test results, physician orders, medication lists and ICD-9CM diagnoses, are stored in an electronic format.
Study Population and Data Abstraction
We reviewed the medical records of all patients at VAPAHCS who, during the period from January 1, 1999, through December 31, 2009, had a newly reported diagnosis of a pleural malignancy (ICD-9CM code 163). We then carried out a review of these records to identify patients who had a pathological diagnosis of MPM. This group of patients constituted the study population.
Two investigators (RV and RF) abstracted individual patient medical records for the time period 1-year before and 1-year after the date of entry of the ICD-9CM code for the diagnosis of pleural malignancy in the medical record or until death, whichever came first. We searched electronic medical records for the documentation of occupational histories, either formally titled as such or embedded in any part of the progress notes. Medical records were specifically reviewed for documentation of the following elements: (1) a job title at any time in the patient’s working life; (2) specific occupational duties; (3) history of asbestos exposures; (4) education provided to patient of asbestos—MPM causation link; (5) referral of patient to a claims board; (6) referral of patient for legal counsel and (7) education provided to patient that MPM may be compensable.
The occupational history elements and healthcare provider interventions targeted in the chart review were established in an a priori manner by WGK.
Data were entered into a spreadsheet (Excel; Microsoft, Redmond, WA). Spreadsheet data were used to calculate the median age and range of study subjects and to tally the frequency and percentages of abstracted chart elements.
The computerized database query identified 26 patients with a diagnosis of pleural malignancy newly entered into their electronic health record during the patient identification period. Of these, 16 had a pathological diagnosis of MPM, which constituted the study population. The median age of the study population at the time of the diagnosis of MPM was 72 years and the range was 51 to 90 years; 15 (94%) were men.
We reviewed all of the notes in patient records from all healthcare providers for the study period. Notes were authored by clinicians spanning a broad range of medical and surgical specialties and allied health fields, who treat the broad range of disorders that would be expected in an elderly population.
A job title, including past or current employment, was documented at least once in the records of 12 (75%) patients. Other than job title, limited details about past occupational and environmental exposures, activities and processes were documented (Table 1
). Details about specific job duties were documented in the records of 2 patients (13%). Documentation of occupational exposure to asbestos, known or presumed, was found in the records of 12 patients (75%). Two patients (75%) were presumed to have had bystander exposure to asbestos, resulting from family members known to have worked with asbestos and believed to have carried fibers into the home setting.
Table 1Health care provider documentation of occupational history and management plan elements (N=16 patients)
MPM, malignant pleural mesothelioma.
Education and Counseling About Causation, Legal Redress and Potential Compensation
Documentation of education and counseling was found in the record of 1 patient. This patient was documented as having asbestos exposure during his service in the U.S. Navy. He was educated about the association between asbestos and MPM, and he was advised to pursue formal evaluation through a compensation and pension panel, which did occur. Beyond this referral, no patient was advised to pursue compensation or seek legal counsel to file a legal claim. There was no documentation of education provided to a patient about the causal association between asbestos and MPM and possible compensation for injury in any of the other records.
We conducted a structured review of the medical records of patients with newly diagnosed MPM to determine the quality of clinician counseling of patients about the strong association between occupational exposure to asbestos and MPM and to assess for documentation of clinician to patient counseling about potential opportunities to pursue legal redress for an occupational illness. Among patients with a new diagnosis of MPM, documentation of some elements of an occupational or environmental history, including an occupational or environmental asbestos exposure history, was common.
We found documentation of education provided to 1 patient about the association between asbestos exposure and MPM. The same patient was advised to pursue compensation for his condition through a compensation panel. There was no documentation of MPM as an occupational cancer in any of the other patients’ records. There was no evidence of education or counseling provided to patients regarding the possibility of legal redress beyond a claims board for MPM. Our findings suggest that clinicians are missing opportunities to provide beneficial information about disease causation and possible compensation to patients to patients with MPM.
Occupational exposures have been recognized as an important contribution to the human cancer burden, exceeded only by the contribution of cigarette smoking and diet.
Occupational Cancer and the NIOSH Carcinogen Policy Guest Column by Paul Schulte PhD NIOSH eNews The Monthly Newsletter of the National Institute for Occupational Safety and Health Director, NIOSH Education and Information Division, Volume 8, Number 12, 2011. Available at: http://www.cdc.gov/niosh/enews/enewsV8N12.html. Accessed July 11, 2011.
Attributing cancer to an occupational exposure is generally challenging on an individual basis; however, malignant mesothelioma is strongly associated with occupational exposure to asbestos and viewed as a sentinel occupational cancer. At least, 65% of all mesothelioma cases and 85% to 90% of male pleural mesothelioma cases may be attributed to occupational asbestos exposure.
Pleural and peritoneal neoplasms.
Timely discussion of management options, including opportunities for compensation, is critical in cases of MPM because of the short anticipated survival of patients. The median survival of MPM is 8 to 14 months.
- Campbell N.P.
- Kindler H.L.
Update on malignant pleural mesothelioma.
- Moore A.J.
- Parker R.J.
- Wiggins J.
- Scherpereel A.
- Astoul P.
- Baas P.
- et al.
European Respiratory Society/European Society of Thoracic Surgeons Task Force.
French Speaking Society for Chest Medicine (SPLF) Experts Group. Guidelines of the French Speaking Society for Chest Medicine for management of malignant pleural mesothelioma.
Malignant pleural mesothelioma: a population-based study of survival.
- Borasio P.
- Berruti A.
- Billé A.
- et al.
Malignant pleural mesothelioma: clinicopathologic and survival characteristics in a consecutive series of 394 patients.
In a 2007 statement, the British Thoracic Society Standards of Care Committee released recommendations on the management of patients with malignant mesothelioma and specifically advised that written information about the disease, its medicolegal aspects and relevant organizations should be available to the patient and family.
- British Thoracic Society Standards of Care Committee
BTS statement on malignant mesothelioma in the UK, 2007.
Details about mechanisms for claim compensation for mesothelioma in the United Kingdom were detailed in this British Thoracic Society statement.
Previous reports have demonstrated mesothelioma is underreported as an occupational cancer depriving some patients of opportunities for compensation. In an analysis of the completeness of reporting of mesothelioma in Ontario, Canada, investigators reviewed data sets from the Ontario Workplace Safety and Insurance Board and the Ontario Cancer Registry and found filing rates for compensation were much lower than the estimated proportion of cases eligible for compensation.
Filing for workers’ compensation among Ontario cases of mesothelioma.
During the period of analysis, 1980–2002, filing rates ranged between 20% and 43%, with substantial heterogeneity by county of diagnosis. Notably, more than 85% of the mesothelioma cases that filed for workers’ compensation in Ontario between 1980 and 2002 were compensated.
In an analysis of reporting of compensable mesothelioma in Alberta, Canada, investigators found 568 histologically confirmed mesothelioma cases between 1980 and 2004.
- Cree M.W.
- Lalji M.
- Jiang B.
- et al.
Under-reporting of compensable mesothelioma in Alberta.
Forty-two percent of cases filed a claim; 83% of filed claims were accepted for compensation. In a study assessing the rate of workers’ compensation for mesothelioma cases in British Columbia, Canada, investigators found compensation rates that were much lower than anticipated and concluded regulatory agencies need to develop policies or effective notification systems to ensure that all newly diagnosed mesothelioma cases seek compensation benefits.
- Kirkham T.L.
- Koehoorn M.W.
- McLeod C.B.
- et al.
Surveillance of mesothelioma and workers’ compensation in British Columbia, Canada.
Pleural mesotheliomas have also been shown to be underreported as occupation cancer in Sweden. In an analysis of 210 cases of MPM found in a cancer registry, only 36% of cases were found in the Swedish Register of Reported Occupational Diseases.
Pleural mesotheliomas are underreported as occupational cancer in Sweden.
Worldwide, malignant mesothelioma is a major public health concern, and its incidence is increasing. The 15-year cumulative frequency of mesothelioma during 1994–2008 in 56 countries reporting mesothelioma was estimated at 174,300. An additional 38,900 cases were estimated in 33 countries that do not report mesothelioma, suggesting one case of mesothelioma has been overlooked for every 4 to 5 reported cases.
- Park E.K.
- Takahashi K.
- Hoshuyama T.
- et al.
Global magnitude of reported and unreported mesothelioma.
We have previously shown that clinicians who manage working age adults with newly diagnosed asthma
- Shofer S.
- Haus B.M.
- Kuschner W.G.
Quality of occupational history assessments in working age adults with newly diagnosed asthma.
and clinicians who manage working age adults with newly diagnosed chronic bronchitis
- Kuschner W.G.
- Hegde S.
- Agrawal M.
Occupational history quality in patients with newly documented, clinician-diagnosed chronic bronchitis.
commonly obtain occupational histories that are incomplete, rarely explore work-related causes of the diseases and rarely counsel patients about prevention and management of work-related asthma and work-related chronic bronchitis. Underreporting of occupational cancers has been demonstrated by other groups.
Underreporting of occupational cancers in Denmark.
- Teschke K.
- Barroetavena M.C.
Occupational cancer in Canada: what do we know?.
- Teschke K.
- van Zwieten L.
Perceptions of the causes of bladder cancer, nasal cancer, and mesothelioma among cases and population controls.
The majority of cases of MPM in men can be linked with occupational exposure to asbestos. Relatively, few cases are attributable to either bystander or environmental exposure to asbestos or have no asbestos exposure history. The significance of a diagnosis of MPM is that the patient may be eligible for compensation with limited dispute compared with other occupational malignancies. Compensation mechanisms vary substantially across the world. Effective strategies to pursue legal redress in one jurisdiction are not necessarily generalizable to other nations or jurisdictions.
The major limitation of our analysis is that we do not know if patients received education about causation and potential for compensation that was not documented in the medical record. An alternative strategy to explore patient education would be to contact surviving patients and/or family members to ask if they recall receiving information about the possibility of legal redress and compensation. Nevertheless, documentation of patient education is recognized as a vital component in the provision of comprehensive patient care.
- Cook L.
- Castrogiovanni A.
- David D.
- et al.
Patient education documentation: is it being done?.
It is possible that some patients received medical care outside of our facility where they may have also obtained beneficial information about MPM and the potential for compensation or were aware of the potential for legal redress through other sources. What remain unknown are details about the total population of patients with MPM who are entitled to compensation for their illness because of occupational exposure.
In summary, among patients with a new diagnosis of MPM, documentation of some elements of an occupational history, including an occupational exposure history, was common. A discussion of probable occupational etiology was found in 1 record, and in 2 cases, it was deduced that bystander asbestos exposure was the exposure setting. Advice to pursue legal counsel was never documented, and referral to a claims board occurred in 1 case. Physicians may be missing opportunities to provide beneficial information to patients with newly diagnosed MPM about the cause of the disease and possible opportunities for legal redress and compensation. Physicians should advise patients and their surrogates that MPM is often a compensable disease.
General practitioners may not feel comfortable managing and counseling the patient with MPM because it is a rare disease. Accordingly, most newly diagnosed patients with MPM, not already being managed by a specialist, should be referred to a pulmonologist or occupational medicine specialist with experience in managing patients with MPM. Specialists should be requested to provide the patient with MPM with relevant details about the causative factors of MPM, prognosis, management options and appropriate information about the potential for legal redress and compensation.
This work was supported by the Palo Alto Institute for Research and Education (to MA and SG-T).
Presented as an abstract at the 2011 American Thoracic Society International Conference.
© 2012 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.