High local unemployment rates limit work after lung transplantation

A Systematized Review of Professional Employment Following Thoracic Transplantation

INTRODUCTION

Acknowledging the evolved landscape in thoracic transplantation, professional employment becomes an important outcome measure to quantify the success of this costly procedure.

OBJECTIVE

We aimed to assess rates of and characterize factors associated with professional employment in patients following thoracic transplantation, and create an evidence-base on the relationship between professional employment and relevant outcome parameters.

METHODS

We systematically searched Medline, Cinahl, and GoogleScholar to identify studies published between 1998 and 2021 reporting on professional employment following heart and lung transplantation.

RESULTS

Twenty-two studies from 11 countries with varying sample sizes (N = 27; 10 066) were included. Employment rates ranged from 19.7% to 69.4% for heart, and from 7.4% to 50.8% for lung transplant recipients. Most frequently reported positively associated factors with employment after transplant were younger age, higher education, and history of pretransplant employment. Longer duration of unemployment prior to transplantation and Medicaid coverage were the most frequently reported negatively associated factors. Relationships between professional employment and clinical outcomes included lower rates of acute and chronic rejection, less infection episodes, and better quality of life among working patients; one study reported a lower 5-year-mortality rate. Reasons not to work were "physical or mental health-related," "employment-related," "financial reasons," and "lifestyle choices."

DISCUSSION

Substantial proportions of patients following thoracic transplantation are not professionally employed, potentially diminishing the success of transplantation on individual and societal levels. Considering adverse clinical outcomes in employed transplant recipients were low, more efforts are needed to identify modifiable factors for employment in these populations.

Health-related quality of life and stress-related post-transplant trajectories of lung transplant recipients: a three-year follow-up of the Swiss Transplant Cohort Study

BACKGROUND Lung transplantation (LTx) provides a viable option for the survival of end-stage lung diseases. Besides survival as a clinical outcome measure, health-related quality of life (HRQoL) and psychological distress have become important outcomes in studies investigating the effectiveness of LTx in the short- and long-term. OBJECTIVE To assess and compare HRQoL trajectories of patients after LTx prior to and over a follow-up period of three years post-transplant, and to identify differences regarding distress, HRQoL and patient-related outcomes. METHODS In this longitudinal study, 27 lung transplant recipients were prospectively examined for psychological distress (Symptom Checklist short version-9; SCL-K-9), health-related quality of life (EuroQOL five dimensions questionnaire; EQ-5D), depression (HADS-Depression scale), and socio-demographic and medical outcomes at two weeks, three months, six months and three years following LTx. Additionally, potential outcome-related predictors for LTx-outcomes at three years post-transplant were assessed. Data were collected in accordance with guidelines set by the STROBE (strengthening the reporting of observational studies in epidemiology) statement. RESULTS Lung transplant recipients showed the most pronounced improvements in HRQoL and reduction in psychological distress between two weeks and three months post-transplant, with relative stable HRQoL and distress trajectories thereafter. The most important predictors of poor somatic health trajectories over time were the pre-transplant disease severity score and the pre-transplant HADS-Depression score. In addition, idiopathic pulmonary fibrosis (IPF) and pre-transplant extracorporeal membrane oxygenation (ECMO)-use predicted poorer survival, while cystic fibrosis was associated with better survival three years post-transplant. COMCLUSION Lung transplantation yields significant survival and HRQoL benefits, with its peak improvement at three months post-transplant. The majority of patients can preserve these health changes in the long-term. Patients with a worse HRQoL and higher psychological distress at six months post-transplant tended to have a poorer survival post-transplant. Other risk factors for poorer survival included IPF, pre-transplant ECMO-use, pre-transplant symptoms of depression, high pre-transplant disease severity and worse somatic disease severity trajectories. The majority of LTx-recipients were unable to work due to illness-related reasons.

Predictive Utility of Lung Allocation Score for Retransplantation Outcomes

BACKGROUND

Treatment of primary graft failure after lung transplantation (LTx) may include retransplantation (rLTx). The number of rLTx cases has doubled since implementation of the Lung Allocation Score in 2005. The Lung Allocation Score was intended to predict LTx outcomes, but its predictive utility has not been assessed in rLTx. We investigated whether 1-year outcomes of LTx and rLTX were equally well predicted by the Lung Allocation Score.

METHODS

Recipients of LTx and rLTx aged 18 years or more were identified in 2005 to 2015 United Network for Organ Sharing data. The Lung Allocation Score was entered in multivariable logistic regression models of 1-year retransplant-free survival. Areas under the receiver-operating characteristics curve summarized model predictive value. We examined whether the Lung Allocation Score and its components were differentially associated with outcomes of LTx and rLTx.

RESULTS

There were 16,837 LTx and 765 rLTx cases meeting inclusion criteria. Crude 1-year retransplant-free survival rates were 86% after LTx compared with 74% after rLTx. On univariate analysis, both LTx and rLTx cohorts showed poor predictive utility of the Lung Allocation Score (area under the curve 0.55 and 0.57, respectively; difference by transplant type, p = 0.307). Neither the Lung Allocation Score nor its components was differentially associated with LTx compared with rLTx outcomes.

CONCLUSIONS

The Lung Allocation Score achieved comparable, but poor, predictive utility for 1-year outcomes of primary LTx and rLTx. We found no evidence that Lung Allocation Score components should be weighted differently for rLTx candidates.

Marital Status and Return to Work After Living Kidney Donation

PURPOSE

Living kidney donation is safe and effective, but patients in need of a transplant continue to outnumber donors. Disincentives to living donation include lost income, risk of job loss, perioperative complications, and unreimbursed medical expenses.

METHODS

This study uses US registry and follow-up data on living kidney donors from 2013 to 2015 to identify social predictors of return to work across gender following living kidney donation.

RESULTS

Using logistic regression, we find that predictors of return to work following living kidney donation differ for women and men. Among women, age, education, smoking status, and procedure type are associated with return to work. Among men, education, procedure type, and hospital readmission within 6 weeks postdonation are associated with return to work. Notably, single and divorced men are less likely to return to work compared to married men (odds ratio [OR] for single men 0.51, 95% confidence interval [CI], 0.37-0.69, P < .001; OR for divorced men 0.51, 95% CI, 0.34-0.75, P = .006). Marital status is not associated with return to work for women. Single and divorced men's greater odds of not returning to work are robust to controls for relevant pre- and postdonation characteristics.

CONCLUSIONS

Single and divorced men's lack of social support may present an obstacle to work resumption following living kidney donation.

County socioeconomic characteristics and heart transplant outcomes in the United States

BACKGROUND

Geographic disparities in survival after heart transplantation have received mixed support in prior studies, and specific geographic characteristics that might be responsible for these differences are unclear. We tested for differences in heart transplant outcomes across United States (US) counties after adjustment for individual-level covariates. Our secondary aim was to evaluate whether specific county-level socioeconomic characteristics explained geographic disparities in survival.

METHODS

Data on patients aged ≥18 years undergoing a first-time heart transplant between July 2006 and December 2014 were obtained from the United Network for Organ Sharing. Residents of counties represented by <5 patients were excluded. Patient survival (censored in March 2016) was analyzed using multivariable Cox regression. Shared frailty models were used to test for residual differences in overall all-cause mortality across counties after adjusting for recipient and donor characteristics. Measures of county economic disadvantage, inequality, and racial segregation were obtained from US Census data and coded into quintiles. A likelihood ratio test determined whether adjusting for each county measure improved the fit of the Cox model.

RESULTS

Multivariable analysis of 10,879 heart transplant recipients found that, adjusting for individual-level characteristics, there remained statistically significant variation in mortality hazard across US counties (P=.004). Adjusting for quintiles of community disadvantage, economic inequality, or racial segregation did not significantly improve model fit (likelihood ratio test P=.092, P=.273, and P=.107, respectively) and did not explain residual differences in patient survival across counties.

CONCLUSIONS

Heart transplantation outcomes vary by county, but this difference is not attributable to county-level socioeconomic disadvantage.

Employment after heart transplantation among adults with congenital heart disease

OBJECTIVE

Adults with congenital heart disease may require heart transplantation for end-stage heart failure. Whereas heart transplantation potentially allows adults with congenital heart disease to resume their usual activities, employment outcomes in this population are unknown. Therefore, we investigated the prevalence and predictors of work participation after heart transplantation for congenital heart disease.

DESIGN

Retrospective review of a prospective registry.

SETTING

United Network for Organ Sharing registry of transplant recipients in the United States.

PATIENTS

Adult recipients of first-time heart transplantation with a primary diagnosis of congenital heart disease, performed between 2004 and 2015.

INTERVENTIONS

None.

OUTCOME MEASURES

Employment status reported by transplant centers at required follow-up intervals up to 5 y posttransplant.

RESULTS

Among 470 patients included in the analysis (mean follow-up: 5 ± 3 y), 127 (27%) worked after transplant, 69 (15%) died before beginning or returning to work, and 274 (58%) survived until censoring, but did not participate in paid work. Multivariable competing-risks regression analysis examined characteristics associated with posttransplant employment, accounting for mortality as a competing outcome. In descriptive and multivariable analysis, pretransplant work participation was associated with a greater likelihood of posttransplant employment, while the use of Medicaid insurance at the time of transplant was associated with a significantly lower likelihood of working after transplant (subhazard ratio compared to private insurance: 0.55; 95% confidence interval: 0.32, 0.95; P = .032).

CONCLUSIONS

Employment was rare after heart transplantation for congenital heart disease, and was significantly less common than in the broader population of adults with congenital heart disease. Differences in return to work were primarily related to pretransplant employment and the use of public insurance, rather than clinical characteristics.

Factors contributing to employment patterns after liver transplantation

BACKGROUND

Many liver transplant recipients return to work, but their patterns of employment are unclear. We examine patterns of employment 5 years after liver transplantation.

METHODS

First-time liver transplant recipients ages 18-60 years transplanted from 2002 to 2009 and surviving at least 5 years were identified in the United Network for Organ Sharing registry. Recipients' post-transplant employment status was classified as follows: (i) never employed; (ii) returned to work within 2 years and remained employed (continuous employment); (iii) returned to work within 2 years, but was subsequently unemployed (intermittent employment); or (iv) returned to work ≥3 years post-transplant (delayed employment).

RESULTS

Of 28 306 liver recipients identified during the study period, 12 998 survived at least 5 years and contributed at least 1 follow-up of employment status. A minority of patients (4654; 36%) were never employed, while 3780 (29%) were continuously employed, 3027 (23%) were intermittently employed, and 1537 (12%) had delayed employment. In multivariable logistic regression analysis, predictors of intermittent and delayed employment included lower socioeconomic status, higher local unemployment rates, and post-transplant comorbidities or complications.

CONCLUSION

Never, intermittent, and delayed employment are common after liver transplantation. Socioeconomic and labor market characteristics may add to clinical factors that limit liver transplant recipients' continuous employment.