The importance of work participation as an outcome in rheumatology

Occupational impacts of early inflammatory arthritis: results from the National Early Inflammatory Arthritis Audit

OBJECTIVES

Inflammatory arthritis causes significant work disability. Studies regarding this frequently fail to report important contextual information such as employment type. Our objective was to explore work participation, by gender and occupation type, in early inflammatory arthritis.

METHODS

Data are from the National Early Inflammatory Arthritis Audit for 2018-2020. At diagnosis, clinicians collected information on demographics, inflammatory arthritis disease activity, and working status. Participants completed patient-reported outcomes at baseline, 3 months and 12 months, including occupation and Work Productivity and Activity Impairment (WPAI). Descriptive analyses of work participation and WPAI scores by occupational class at all time points were performed. Regression models were used to examine associations between WPAI score and occupation.

RESULTS

In all, 12 473 people received a diagnosis of inflammatory arthritis and reported employment status, among whom 5999 (47%) were in paid work for at least 20 hours/week. At diagnosis, the working cohort had statistically significant lower measures of disease activity (P < 0.001). Occupational data were available for 3694 individuals. At diagnosis, 2793 completed a WPAI; 200 (7.2%) had stopped work and 344 (12.3%) changed jobs because of inflammatory arthritis symptoms. There was a high burden of absenteeism (30%) and presenteeism (40%). Compared with managerial or professional workers, the burden of work disability was greater among those in routine (manual) occupations. During follow-up, 9.4% of WPAI completers stopped work and 14.6% changed roles. Work drop-out occurred almost entirely among people doing routine jobs.

CONCLUSION

It is easier to retain work in certain employment sectors. Participation in routine jobs is more affected, which may widen health inequalities.

The role of occupational therapy in providing vocational rehabilitation for inflammatory arthritis: A scoping review protocol

INTRODUCTION

Inflammatory arthritis (IA) significantly impacts people's ability to continue in work roles, despite advances in medical management. Employment is acknowledged as important for health and wellbeing. Facilitating work participation and employment reduces social welfare dependence for income, minimising societal cost. Internationally, pathways and processes are developing to maintain people with acquired conditions in the workplace. Occupational Therapy supports this process, with its biopsychosocial approach, giving a framework to consider the complex dynamic of a person's vocational rehabilitation (VR) needs. A scoping review framework was chosen to explore the diverse VR process and emerging focus on Occupational Therapy's role in providing VR for the IA population.

METHODS

The methodological framework for scoping reviews will be used to guide the process and structure of the scoping review. A search strategy will be implemented in all the major peer reviewed databases along with grey literature repositories for English language studies. Study selection will use the PRISMA-ScR flow chart against an agreed eligibility criteria by two independent reviewers. Data extraction from the final selection will be mapped out using tables and a supporting descriptive review reflecting on the original scoping review aim and objectives completed.

DISSEMINATION

Findings will be disseminated at all levels and in various formats to bring them to the attention of clinicians, researchers and policy makers as VR pathways are established and prioritised for the early IA population.

Morbidities among older workers and work exit: the HEAF cohort

BACKGROUND

Governments need people to work to older ages, but the prevalence of chronic disease and comorbidity increases with age and impacts work ability.

AIMS

To investigate the effects of objective health diagnoses on exit from paid work amongst older workers.

METHODS

Health and Employment After Fifty (HEAF) is a population cohort of adults aged 50-64 years recruited from English GP practices which contribute to the Clinical Practice Research Datalink (CPRD). Participants have completed questionnaires about health and work at baseline and annually for 2 years: their responses were linked with their objective health diagnoses from the CPRD and data analysed using Cox regression.

RESULTS

Of 4888 HEAF participants ever in paid work, 580 (25%) men and 642 (25%) women exited employment, 277 of them mainly or partly for a health reason (health-related job loss (HRJL)). Amongst HEAF participants who remained in work (n = 3666) or who exited work but not for health reasons (n = 945), there was a similar prevalence of background health conditions. In men and women, HRJL was associated with inflammatory arthritis, sleep disorders, common mental health conditions and musculoskeletal pain. There were however gender differences: widespread pain and lower limb osteoarthritis were associated with HRJL in women but hypertension and cardiovascular disease in men.

CONCLUSIONS

Improved diagnosis and management of common conditions might be expected to increase working lives. Workplace well-being interventions targeting obesity and increasing mobility might contribute to extended working lives. Employers of predominantly female, as compared with male workforces may need different strategies to retain older workers.

'You don't want to be seen as a burden' experiences of working with early inflammatory arthritis: a qualitative study

PURPOSE

To describe the impact of early inflammatory arthritis on work participation.

MATERIALS AND METHODS

Thirty individuals (24 women) of working age (age 18-69 years) with inflammatory arthritis (<2 years duration) who were in paid employment or fulltime education were interviewed using qualitative description methodology. Data was analysed using thematic analysis.

RESULTS

Half of participants (n = 15) reported work disability within the first two-years of diagnosis. Five descriptive themes were identified that explained the early impact of IA on participation in paid employment. These themes were: (i) altered capacity for work; (ii) work comes first; (iii) the invisible burden; (iv) the disclosure effect; and (v) a reconstructed work future.

CONCLUSION

The scale of early work disability appears to be higher than previously understood. Although early medical intervention has improved disease management, significant work-based restrictions requiring intervention remain. Internalised and invisible work-related anxieties present early in the disease and need to be acknowledged and addressed by healthcare providers.IMPLICATIONS FOR REHABILITATIONEarly inflammatory arthritis causes significant challenges in work ability, and early work-based participation restrictions are present despite early use of drug therapy.Assessment of the client's subjective experience, including understanding the invisible burden, is an important aspect in determining the types of work interventions required.Disclosure of diagnosis in the work environment is associated with anxiety and fear, however, disclosure is influential in supporting capacity to retain work participation and should be included in work interventions.Routine healthcare should include early interventions to address work-based restrictions and supporting work retention to avoid work disability.

Comparative construct validity of three presenteeism instruments in workers with musculoskeletal complaints: a prospective cohort study

OBJECTIVES

To compare the construct validity of three presenteeism instruments, using health and economic outcomes as external references, among working persons reporting musculoskeletal complaints.

METHODS

Data from the prospective Study on Transitions in Employment, Ability and Motivation were used. Presenteeism measurement comprised a global rating of work-ability, and two instruments indicating at-work productivity, and was assessed yearly over 6 years of follow-up. Longitudinal associations between measures of health and subsequent presenteeism, and between presenteeism and subsequent days of sick leave were assessed using generalised estimating equation models. The effect of groups of contextual factors (socio-demographic, lifestyle, personal and work-related factors) was investigated by assessing the change in explained variability.

RESULTS

In total, 4523 persons were analysed. The association between physical health and work-ability was stronger than both at-work productivity measures; 10 points increase in physical health (0-100, higher is better) was associated with 0.79 points (95% CI 0.75 to 0.84) better work-ability (0-10, higher is better) in the subsequent year. Besides, work-ability best predicted sick leave; one point higher work-ability was associated with 4 days less sick leave (95% CI -5.09 to -3.63) the subsequent year. Personal factors improved model fit for models on health and work-ability, but conflicting results were seen for both at-work productivity instruments.

CONCLUSION

Work-ability showed higher construct validity against health and economic outcomes as compared to at-work productivity, which shows that work-ability is different to productivity (losses). Personal factors are especially relevant when interpreting the relation between health and work-ability or self-reported quantity of work.

Health and work: what physicians need to know

Employment, along with education, is central to the promotion of social mobility and the reduction of health inequalities. For the most part, however, physicians have limited exposure to occupational medicine during their training and rarely receive much in the way of formal training about occupational issues except those that fall commonly within their area of specialisation. Here, we illustrate why work and good employment can be so important for health and, therefore, why it should matter to all physicians. Given that under half of the UK population have access to occupational health services through their employer, physicians should be able to recognise any harm to health caused by work, so we describe the principles of eliciting a good occupational history. There is an important relationship between unemployment and poor health which will be discussed, illustrating the importance of being able to support people with long-term conditions and disabilities to remain in work for as long as they wish to do so. Patients expect to be able to seek advice from their physician about taking time off work because of ill health, planning a return to work after sickness absence and whether or not they need to change their work status because of their health condition. Therefore, we describe the fitnote: what it is for, how to complete one well and what core principles are needed in order to give patients good advice about working.

Outcomes and treatment responses, including work productivity, among people with axial spondyloarthritis living in urban and rural areas: a mixed-methods study within a national register

Objective

To examine differences in clinical and patient-reported outcomes, including work, in individuals with axial spondyloarthritis (axSpA) living in rural and urban settings.

Methods

Using a sequential, explanatory mixed-method design, data from the British Society for Rheumatology Biologics Register for Ankylosing Spondylitis were used to (1) characterise participants with axSpA living in rural and urban areas and (b) assess any differences in outcome after commencement of biologic therapy (phase 1). Semistructured interviews (phase 2) further explored the results from phase 1.

Results

Patients with axSpA living in rural areas were older and more likely to work in a physical job. Among patients prescribed biologics, there were no differences in response to biologics, but after adjustment for age, sex and local area deprivation rural dwellers reported more presenteeism and overall work impairment. Work effects could be explained by accounting for individual differences in disease activity, fatigue, physical function and job type. Interviews highlighted the complex relationship between clinical factors, contextual factors (work environment, job demands) and work disability. The ability to work and flexibility in terms of what, when and how tasks are undertaken were important. Support from employers was variable and healthcare professionals were often perceived as unsupportive.

Conclusions

Patients with axSpA living in rural areas report a greater impact of their disease on work productivity. New measures are needed to capture important contextual factors and comprehensively determine the impact of long-term conditions on work. Future European League Against Rheumatism axSpA recommendations should include support to work as a target to optimise quality of life in patients with axSpA.

Early arthritis clinic is cost-effective, improves outcomes and reduces biologic use

There is good evidence that dedicated early arthritis clinics (EACs) improve referral lag time and reduce delay in establishing disease-modifying therapy. However, it remains arguable whether such clinics improve relevant disease outcomes. Nationally, only 57% of units have dedicated EACs. Our rheumatology department established a centralised, patient-focused and multidisciplinary EAC to achieve key financial and clinical outcome targets the department was failing to meet. The EAC aimed to increase the department's capacity to accommodate referrals from general practitioners (GPs) and other sources, decrease the time between diagnosis and starting therapy, establish standardised treatment algorithms and reduce biologic use. The EAC was established in January 2016 and comprised the introduction of a dedicated referral pro forma and an EA educational programme for GPs, pooling of all sources of referral, running of six EACs per week with availability of ultrasound and introduction of a standardised approach to the early initiation of therapy and timely review of treatment outcomes. The introduction of the EAC was associated with improved clinical outcomes (EA patients achieving a Disease Activity Score 28 (DAS28) < 3.2 in 2015, 38.0% [N = 113] vs. 78.5% [N = 220] in 2016) and overall patient experience (mean waiting time for EA patients' first appointment in 2015: 12 weeks vs. 2.5 weeks in 2016; 94% [N = 167] of patients recommended the rheumatology service in 2016 vs. 74% [N = 100] in 2015). The total costs associated with introducing the EAC were ~ £201,362. Use of biologics decreased from 26.0 to 5.6% between 2015 and 2016, resulting in a cost saving of ~ £394,942. Other cost savings associated with the EAC included reductions in the overall cost/patient seen (2015, £198.88; 2016, £74.98) and not running any premium rate initiative clinics (saving ~ £26,500 in 2016) to meet waiting list targets. Efficiency gains from the introduction of the EACs have improved patients' health and overall satisfaction with their treatment, whilst saving costs for healthcare.

The experience of foot problems and decisions to access foot care in patients with rheumatoid arthritis: a qualitative study

Background

Although foot problems are common in rheumatoid arthritis (RA), the consequences of foot problems from the patient perspective have not been fully explored. The aims of this study were to explore the experience of foot problems and decisions to access foot care services or not in patients with RA.

Methods

Semi structured, one-to-one interviews with patients recruited from 2 UK rheumatology units, purposively sampled for self-reported foot problems and a range of personal/disease characteristics. Inductive thematic analysis was used, with rigour provided by multiple independent analysers. Emerging themes were discussed and agreed by all authors.

Results

Twelve patients participated: 7 female; mean age 56 years (29–72); mean disease duration 12 years (2–27), 5 had accessed foot care services. The ‘Impact’ of foot problems was substantial and formed the underpinning theme, comprising three organising themes: ‘Foot symptoms’; ‘Consequences’; and ‘Cost’. Foot symptoms such as pain and numbness required self-management, and affected daily life (walking, working) leading to social and emotional costs. The global theme, ‘Decision to access foot care or not’, also comprised three organising themes: ‘Access perceived unnecessary’ (no problem, can cope); ‘Access hindered by patients’ perception’; and ‘Access supported by patient and clinician’. Decisions to access foot care or not were complex and influenced by patient beliefs regarding possible treatments and how to access these, and hindered by patient perceptions that their feet were ignored by rheumatology clinicians. Positive experience of foot care encouraged continued utilisation but negative experiences contributed to patients’ decisions to discontinue foot care services.

Conclusions

Foot problems are important issues for patients and impact on many aspects of their physical, social and emotional lives. Patients who had accessed foot care services prioritised their foot problems as an important health care need. However, for others who would like foot care services, personal knowledge and values, and perceived barriers in clinical practice, appear to interact to inhibit foot care access. The extent which these interactions affect overall access to foot care in RA patients in general now needs to be quantified to help to inform and improve the effectiveness of the organisation and delivery of foot care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13047-017-0188-3) contains supplementary material, which is available to authorized users.