Effect of Rheumatoid Arthritis on Longterm Sickness Absence in 1994-2011: A Danish Cohort Study

Work participation and the COVID-19 pandemic: an observational study in people with inflammatory rheumatic diseases and population controls

Objective

During the coronavirus disease 2019 (COVID-19) crisis, people with inflammatory rheumatic diseases (iRDs) might have been more vulnerable for adverse work outcomes (AWOs) and restrictions in work ability and work performance. Our objectives were to compare AWOs during the pandemic and current work ability between iRD patients and controls, understand which patients are most vulnerable for these outcomes and (3) explore the role of work characteristics on work performance while working remotely.

Methods

Patients and population controls in a Dutch COVID-19 cohort study provided information in March 2022 on work participation in March 2020 (pre-pandemic, retrospective) and March 2022 (current). AWOs comprised withdrawal from paid work, working hours reduction or long-term sick leave. Multivariable logistic/linear regression analyses compared outcomes (AWOs/work ability) between groups (patients/controls) and within patients.

Results

Of the pre-pandemic working participants, 227/977 (23%) patients and 79/430 (18%) controls experienced AWOs following pandemic onset. A minority of AWOs (15%) were attributed to COVID-19. Patients were more likely to experience any-cause AWOs (odds ratio range 1.63-3.34) but not COVID-related AWOs, with female patients and patients with comorbidities or physically demanding jobs being most vulnerable. Current work ability was lower in female patients compared with controls [β = -0.66 (95% CI -0.92 to -0.40)]. In both groups, when working remotely, care for children and absence of colleagues had varying effects on work performance (positive 19% and 24%, negative 34% and 57%, respectively), while employer support and reduced commuting had mainly positive effects (83% and 86%, respectively).

Conclusion

During the pandemic, people with iRDs remained at increased risk of AWOs. COVID-related AWOs, however, were infrequent.

Developing a complex vocational rehabilitation intervention for patients with inflammatory arthritis: the WORK-ON study

BACKGROUND

People with inflammatory arthritis often experience challenges at work and balancing paid work and energy in everyday life. Low work ability is common, and people with inflammatory arthritis face high risks of losing their jobs and permanent exclusion from the labour market. Context-specific tailored rehabilitation targeting persons with inflammatory arthritis is limited. The aim of this study is to describe the development of WORK-ON - a vocational rehabilitation for people with inflammatory arthritis.

METHODS

Following the Medical Research Council's framework for complex interventions, WORK-ON was developed based on existing evidence, interviews with patients and rehabilitation clinicians, a workshop, and an iterative process.

RESULTS

The six-month vocational rehabilitation, WORK-ON, consists of 1) an initial assessment and goal setting by an occupational therapist experienced in rheumatology rehabilitation, 2) coordination by the same occupational therapist and individual support, including navigating across the primary and secondary health sectors, as well as social care, 3) group sessions for peer support, and 4) optionally individually tailored consultations with physiotherapists, nurses, or social workers.

CONCLUSION

WORK-ON is ready to be tested in a feasibility study.

TRIAL REGISTRATION

The Regional Committees on Health Ethics for Southern Denmark stated that no formal ethical approval was necessary in this study (20,192,000-105).

Barriers and facilitators for coherent rehabilitation among people with inflammatory arthritis - a qualitative interview study

BACKGROUND

People with chronic diseases have contact with several different professionals across hospital wards, municipality services and general practice and often experience lack of coherence. The purpose was to explore perceived barriers and facilitators to coherent rehabilitation pathways for health care users with inflammatory arthritis and how coherence can be improved.

METHODS

Semi-structured individual interviews were conducted before a planned inpatient rehabilitation stay, 2-3 weeks and 4-6 months after discharge. Thematic reflexive analysis guided the analysis of data. Concepts of person-centred care, complex adaptive systems and integrated care were applied in the interpretations.

RESULTS

In all, 11 participants with IA were included. There was one overarching theme, The importance of a person-centred approach, illuminating the significance of professionals who respect healthcare user' preferences. To use a person-centred approach, demands professionals who are interested in exploring the persons own values, preferences and experiences and incorporate these when planning care and rehabilitation.Connected to the overarching theme, three sub-themes were derived; 1) Experiences of empowerment and dis-empowerment, covering that most want to be in control and act themselves, but felt overwhelmed and lost energy and they tended to give up; 2) Experiences of communication and coordination, encompass how people feel forced to take on coordination and communication tasks themselves although they do not always feel qualified for this. Some asked for a coordination person and 3) Facing everyday life after discharge, covering how initiatives taken by professionals were not always experienced as helpful after discharge. Some gave up and some tried to find alternative paths themselves.

CONCLUSION

Professionals taking a person-centred approach facilitated coherent rehabilitation pathways. This encompassed care with respect for individual needs and professionals who empowered patients to self-management. Furthermore, to be aware that interprofessional communication and coordination need to take place both between professional within the same department, between departments and between professionals in different sectors. After discharge, some patients were challenged in their everyday life when trying to follow the advice from the professionals. Professionals, who do not use a person-centred approach, hinder coherence. Patients thus feel compelled to take on communication and coordination tasks.

A Systematic Review of Job Loss Prevention Interventions for Persons with Inflammatory Arthritis

Purpose To present an overview of the evidence of the effect of job loss prevention interventions, aiming to improve work ability and decrease absenteeism and/or job loss in persons with inflammatory arthritis (IA). Method A systematic literature search in the databases PubMed, EMBASE, CINAHL, PsycINFO and the Cochrane Library was conducted. A search strategy used in a review from 2014 was copied and additional keywords were added with no time restriction. The Cochrane Risk of Bias Tool (RoB 1) was used for quality assessment and the overall quality of each study was determined using predetermined cut-off criteria, categorising studies to be of good-, acceptable- or low quality. Results were summarised narratively. Results Six randomised controlled trials (published in seven articles) were included, one of good quality and five of acceptable quality. One study identified significant improvements in work ability, while three found no significant difference between groups. One study identified significant difference in absenteeism, while two studies identified no difference between the intervention and control groups. Two studies identified significant reduction in job loss, while two studies identified no group difference. The inconsistent results may be due to heterogeneity in interventions and outcome measures used, and the results should therefore be interpreted with caution. Conclusion The results indicate that job loss prevention interventions may have an effect on work ability, absenteeism and in particular job loss among persons with IA. Further good-quality studies regarding job loss prevention interventions for people with IA are still recommended.

Perceived challenges at work and need for professional support among people with inflammatory arthritis - a qualitative interview study

BACKGROUND

People with inflammatory arthritis (IA) often experience low work ability, and up to 38% lose their jobs during the initial years after the diagnosis of IA.

AIM

We explore the perceived challenges at work and identify the need for professional support among Danish people with IA.

MATERIALS/METHODS

Individual explorative interviews based on a hermeneutic approach. We used Graneheim and Lundman's qualitative content analysis.

RESULTS

Eleven women and four men with IA (aged 36-68 years) who worked full or part time, or were on short-term sick leave, participated. The analysis revealed one main theme, Balancing work as part of everyday life, and four sub-themes: 1) Working despite challenges, 2) Prioritising energy for work, 3) Fatigue leading to lack of control, and 4) Need for flexibility and recognition.

CONCLUSIONS

People with IA prioritise staying at work despite experiencing challenges with fatigue and balancing their work and energy in everyday life. They need recognition, support and flexibility at work to be able to continue in their jobs.

SIGNIFICANCE

The study highlights the need to be aware of occupational balance and, thus, to include other aspects in life apart from just work. It points at occupational therapists as relevant partners in vocational rehabilitation.

Methodological aspects of design, analysis and reporting of studies with work participation as an outcome domain in patients with inflammatory arthritis: results of two systematic literature reviews informing EULAR points to consider

Objective

To summarise the methodological aspects in studies with work participation (WP) as outcome domain in inflammatory arthritis (IA) and other chronic diseases.

Methods

Two systematic literature reviews (SLRs) were conducted in key electronic databases (2014–2019): search 1 focused on longitudinal prospective studies in IA and search 2 on SLRs in other chronic diseases. Two reviewers independently identified eligible studies and extracted data covering pre-defined methodological areas.

Results

In total, 58 studies in IA (22 randomised controlled trials, 36 longitudinal observational studies) and 24 SLRs in other chronic diseases were included. WP was the primary outcome in 26/58 (45%) studies. The methodological aspects least accounted for in IA studies were as follows (proportions of studies positively adhering to the topic are shown): aligning the studied population (16/58 (28%)) and sample size calculation (8/58 (14%)) with the work-related study objective; attribution of WP to overall health (28/58 (48%)); accounting for skewness of presenteeism/sick leave (10/52 (19%)); accounting for work-related contextual factors (25/58 (43%)); reporting attrition and its reasons (1/58 (2%)); reporting both aggregated results and proportions of individuals reaching predefined meaningful change or state (11/58 (16%)). SLRs in other chronic diseases confirmed heterogeneity and methodological flaws identified in IA studies without identifying new issues.

Conclusion

High methodological heterogeneity was observed in studies with WP as outcome domain. Consensus around various methodological aspects specific to WP studies is needed to improve quality of future studies. This review informs the EULAR Points to Consider for conducting and reporting studies with WP as an outcome in IA.

Deployment experiences and mental health problems as predictors of post-deployment unemployment length: a prospective, register-based study among Danish soldiers

OBJECTIVES

To test responses of formerly deployed soldiers (FDS) to a questionnaire on deployment experiences in combination with screening levels of post-traumatic stress disorder (PTSD) and depression approximately 6 months after homecoming as predictors of the subsequent probability of gaining employment when unemployed within 5 years post-deployment.

DESIGN, SETTING AND PARTICIPANTS

Danish FDS responders (n=3935) and non-responders (n=3046) to a 6-month post-deployment screening questionnaire after returning from a first-ever deployment to Kosovo, Iraq or Afghanistan (2002 to 2012) were included in the study and followed in public registers from 6 months to 5 years post-deployment.

PRIMARY AND SECONDARY OUTCOME MEASURES

We tested Cox regression models including deployment experiences (1a), screening levels of PTSD and depressive symptoms (1b), and their combination (2) for FDS responders. For all FDS, a secondary model included a measure on whether they responded to the questionnaire (3).

RESULTS

Neither the deployment experiences (1a) of exposure to danger and combat (HR=1.00, 95% CI=0.97 to 1.03) and witnessing consequences of war (HR=1.01, 95% CI=0.96 to 1.06), or the screening levels (1b) of PTSD (HR=1.06, 95% CI=0.84 to 1.33) and depressive symptoms (HR=0.82, 95% CI=0.64 to 1.06) were significant predictors of transitioning from unemployment to employment. Similar results were found for the combined model (2). A tendency among non-respondents (3) to have a lower probability of transitioning from unemployment to employment was found (HR=0.90, 95% CI=0.81 to 1.00).

CONCLUSION

Deployment experiences, PTSD and depressive symptoms, as measured at 6-month screening questionnaire, did not predict differences in the probability of gaining employment when unemployed within 5 years post-deployment. However, the findings suggest that those with the least probability of transitioning from unemployment to employment can be found among the non-responders to the post-deployment screening questionnaire.

Increased risk of long-term sickness absence, lower rate of return to work and higher risk of disability pension among people with type 1 and type 2 diabetes mellitus: a Danish retrospective cohort study with up to 17 years' follow-up

AIM

To evaluate labour market outcomes in type 1 or type 2 diabetes.

METHODS

Individuals with type 1 (n = 431) and type 2 diabetes (n = 4047) were identified in Danish national registers from 1994 to 2011 and compared with individuals without diabetes (n = 101 295). Multi-state Cox proportional hazards analyses estimated hazard ratios (HR) with 95% confidence intervals (CI) for transitions between work, sickness absence, unemployment and disability pension.

RESULTS

We observed significantly higher HR of sickness absence in type 1 diabetes (women: 1.34, 95% CI 1.12-1.62; men: 1.43, 1.01-2.03) and type 2 diabetes (women: 1.46, 95% CI 1.35-1.58; men: 1.64, 1.46-1.85) compared with people without diabetes. HR of unemployment was higher for men with type 1 diabetes (1.25, 95% CI 1.01-1.53) and women with type 2 diabetes (1.09, 95% CI 1.03-1.16) and men with type 2 diabetes (1.17, 95% CI 1.08-1.27). HR of disability pension was higher in type 1 diabetes (women: 1.90, 95% CI 1.46-2.46; men: 2.09, 1.38-3.18) and type 2 diabetes (women: 1.78, 95% CI 1.62-1.96; men: 2.11, 1.86-2.40). Only women with type 2 diabetes were less likely to return to work from sickness absence (HR 0.91, 95% CI 0.86-0.98) or unemployment (0.89, 95% CI 0.85-0.94). We found no significant difference between the two types of diabetes. Hazard ratios for diabetes regarding unemployment, sickness absence while unemployed and disability pension were significantly higher for men than for women.

CONCLUSIONS

Both type 1 and type 2 diabetes affect labour market outcomes, but future studies should also consider comorbidity and social gradient.

Sustained improvement in work outcomes in employed patients with rheumatoid arthritis during 2 years of adalimumab therapy: an observational cohort study

Objective

The goal of this study was to evaluate the long-term impact of adalimumab therapy on work-related outcomes in employed patients with rheumatoid arthritis (RA).

Method

We utilized data from an observational cohort of German patients who initiated adalimumab treatment during routine clinical care. Analyses were based on employed patients (part-time or full-time) who continued adalimumab treatment for 24 months. Major outcomes were self-reported sick leave days in the previous 6 months, absenteeism, presenteeism, and total work productivity impairment as assessed by the Work Productivity and Activity Impairment (WPAI) questionnaire and disease activity assessments. The normal number of sick leave days was based on data from the German Federal Statistical Office.

Results

Of 783 patients, 72.3% were women, mean age was 47.9 years, and mean disease duration was 7.8 years. At baseline (before adalimumab initiation), 42.9% of patients had higher than normal sick leave days (> 5) in the previous 6 months. During 24 months of adalimumab treatment, 61% of patients with higher than normal sick leave days at baseline returned to normal sick leave values (≤ 5 days/6 months). Overall, mean sick leave days/6 months decreased from 14.8 days at baseline to 7.4 days at month 24. Improvements were observed in WPAI assessments and disease activity measures, although presenteeism levels remained high (32.2% at month 24).

Conclusions

Adalimumab treatment was associated with strong and sustained improvements in work-related outcomes in employed patients who continued on adalimumab for 24 months. Presenteeism appears to be the work outcome most resistant to improvement during RA treatment.

Trial registration

NCT01076205

Key Points • Long-term adalimumab therapy was associated with sustained improvements in work outcomes in patients with rheumatoid arthritis. • Despite improvements in sick leave days and work absenteeism, presenteeism (impairment while at work) remained relatively high.

Relationship between the physician-based clinical scale for foot and ankle surgery and patient-reported outcomes in patients with long-standing rheumatoid arthritis: Results from a multicenter prospective observational cohort study

OBJECTIVES

To validate and establish targets for the physician-based clinical scale for foot surgery in rheumatoid arthritis (RA) patients based on patient-reported outcomes from a multicenter prospective cohort.

METHODS

We collected data on demographics, values from the RA foot and ankle scale by the Japanese Society for Surgery of the Foot (JSSF-RA), and patient-reported outcomes (PROs) including the Health Assessment Questionnaire Disability Index (HAQ-DI) before (baseline) and 6 and 12 months after joint surgery. Target values for JSSF-RA were determined according to the lower limit of the 95% CI of JSSF-RA in patients with HAQ-DI ≤0.5 after adjusting for age and sex. We used multiple linear regression analysis to examine potential predictors of JSSF-RA target achievement at baseline.

RESULTS

Cross-sectional analysis was conducted on data from 417 cases. The JSSF-RA target for foot and ankle surgery was set at 74 according to the JSSF-RA value corresponding to HAQ-DI ≤0.5 (mean 77.6, 95% CI: 74.3-80.9). Longitudinal analysis of patients who underwent foot surgery (N = 59) determined target cut-off values of 1.188 and 65 for HAQ-DI and JSSF-RA at baseline, respectively, as being predictive for achieving JSSF-RA ≥74 after surgery.

CONCLUSIONS

A JSSF-RA value of 74 represents an important target for patients with RA who have undergone foot surgery. In order to achieve this target, the timing of the surgery should be considered in the treatment of established RA patients.

Work Ability and Employment in Rheumatoid Arthritis: A Cross-Sectional Study on the Role of Muscle Strength and Lower Extremity Function

Objective

The aim of the present study was to assess the association between muscle strength, lower extremity function, employment status, and work ability in RA patients.

Methods

One hundred seropositive RA outpatients of working age were included in this cross-sectional study. Employment status was assessed by interview and work ability by the Work Ability Index-Single Item Scale (WAS). Muscle strength was determined using dynamometer measurement of isometric hand grip and knee extensor strength. Lower extremity function was measured using the short physical performance battery (SPPB). Regression models estimate the association between unemployment, work ability and muscle strength, and lower extremity function, controlling for sociodemographic and disease-related factors.

Results

Forty-one percent of the RA patients were not gainfully employed, and their median work ability had a good WAS value (7.00 [4.00-7.00]). Patients with better knee extensor strength (OR=1.07, 95% CI [1.02-1.12) and better physical performance (OR=1.71, 95% CI [1.18-2.49]) had a significantly better chance of gainful employment. The odds for hand grip strength remained significant when adjusted for sociodemographic (OR=1.5, 95% CI [1.00-1.09]), but not for disease-specific variables. Better hand grip strength (β=0.25, p=0.039) and better knee extensor strength (β=0.45, p=0.001) as well as better lower extremity function (SPPB) (β=0.51, p<0.001) remained significantly associated with work ability following adjustment for sociodemographic and disease-specific variables.

Conclusions

The association of employment status and work ability with parameters of physical fitness suggests that improvement in muscle strength and lower extremity function may positively influence work ability and employment in individuals with RA.

Long-term sickness absence of 32 chronic conditions: a Danish register-based longitudinal study with up to 17 years of follow-up

OBJECTIVES

Sickness absence has been used as a central indicator of work disability, but has mainly been examined in single diseases, with limited follow-up time. This study identified the risk of long-term sickness absence (LTSA) of 32 chronic disease groups in the first year after diagnosis and the subsequent years.

SETTING

We identified chronic disease groups prevalent in the work force (26 physical and 6 mental conditions) requiring all levels of care (primary, secondary, tertiary), by national registers of diagnoses from all hospital visits and prescribed medicine in Denmark from 1994 to 2011.

PARTICIPANTS

A general population sample within the working age range (18-59 years) was drawn by Statistics Denmark. Participants not working before and during the follow-up period were excluded. A total of 102 746 participants were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

HRs of transitions from work to LTSA of each of the chronic conditions were estimated in Cox proportional hazards models for repeated events-distinguishing between risk within the first (<1 year) and subsequent years of diagnosis (≥1 year) and an HR ratio (HRR): HR ≥1 year divided by HR <1 year.

RESULTS

Almost all the conditions were associated with significantly increased risks of LTSA over time. The risks were generally more increased in men than in women. Three main patterns of LTSA were identified across diseases: strong decreases of LTSA from the first to subsequent years (eg, stroke in men <1 year: HR=7.55, 95% CI 6.45 to 8.85; ≥1 year HR=1.43, 95% CI 1.20 to 1.74; HRR=0.23). Moderate or small decreases in LTSA (HRR between 0.46 and 0.76). No changes (HRR between 0.92 and 0.95) or increases in elevated risks of LTSA over time (HRR between 1.02 and 1.16).

CONCLUSIONS

The 32 chronic diseases were associated with three different risk patterns of LTSA over time. These patterns implicate different strategies for managing work disability over time.

Sickness absence due to different musculoskeletal diagnoses by occupational class: a register-based study among 1.2 million Finnish employees

Objectives

Those in lower occupational classes have an increased risk of sickness absence due to musculoskeletal diseases (MSDs), but studies examining the associations simultaneously across specified diagnostic groups within MSDs are lacking. We examined occupational class differences in the occurrence and length of long-term sickness absence due to different musculoskeletal diagnoses.

Methods

A 70% random sample of employed Finns aged 25–64 years old at the end of 2013 was linked to data on sickness absence of over 10 working days obtained from The Social Insurance Institution of Finland and occupational class from Statistics Finland. Sickness absences due to MSDs initiated in 2014 were followed until the end of each episode for female (n=675 636) and male (n=604 715) upper non-manuals, lower non-manuals and manual workers. Negative binomial hurdle models were used to analyse the associations.

Results

Within the studied MSDs, the most common causes of absence were back disorders, particularly back pain, and shoulder disorders. Osteoarthritis, disc disorders and rheumatoid arthritis induced the longest episodes of absence. Clear hierarchical class differences were found throughout, but the magnitude of the differences varied across the diagnostic causes. The largest class differences in the occurrence were detected in shoulder disorders and back pain. The class differences in length were greatest in rheumatoid arthritis, disc disorders and, among men, also in hip osteoarthritis.

Conclusions

Hierarchical occupational class differences were found across different MSDs, with large differences in back and shoulder disorders. Occupational class and diagnosis should be considered when attempting to reduce sickness absence due to MSDs.

Worklife expectancy in a cohort of Danish employees aged 55-65 years - comparing a multi-state Cox proportional hazard approach with conventional multi-state life tables

Background

Work life expectancy (WLE) expresses the expected time a person will remain in the labor market until he or she retires. This paper compares a life table approach to estimating WLE to an approach based on multi-state proportional hazards models. The two methods are used to estimate WLE in Danish members and non-members of an early retirement pensioning (ERP) scheme according to levels of health.

Methods

In 2008, data on self-rated health (SRH) was collected from 5212 employees 55–65 years of age. Data on previous and subsequent long-term sickness absence, unemployment, returning to work, and disability pension was collected from national registers. WLE was estimated from multi-state life tables and through multi-state models.

Results

Results from the multi-state model approach agreed with the life table approach but provided narrower confidence intervals for small groups. The shortest WLE was seen for employees with poor SRH and ERP membership while the longest WLE was seen for those with good SRH and no ERP membership. Employees aged 55–56 years with poor SRH but no ERP membership had shorter WLE than employees with good SRH and ERP membership. Relative WLE reversed for the two groups after age 57.

At age 55, employees with poor SRH could be expected to spend approximately 12 months on long-term sick leave and 9–10 months unemployed before they retired – regardless of ERP membership. ERP members with poor SRH could be expected to spend 4.6 years working, while non-members could be expected to spend 7.1 years working.

Conclusion

WLE estimated through multi-state models provided an effective way to summarize complex data on labor market affiliation. WLE differed noticeably between members and non-members of the ERP scheme. It has been hypothesized that while ERP membership would prompt some employees to retire earlier than they would have done otherwise, this effect would be partly offset by reduced time spent on long-term sick leave or unemployment. Our data showed no indication of such an effect, but this could be due to residual confounding and self-selection of people with poor health into the ERP scheme.

Characteristics of functional impairment in patients with long-standing rheumatoid arthritis based on range of motion of joints: Baseline data from a multicenter prospective observational cohort study to evaluate the effectiveness of joint surgery in the treat-to-target era

OBJECTIVE

To explore the characteristics of functional impairment in patients with established rheumatoid arthritis (RA) based on the range of motion (ROM) of joints in a prospective observational study of RA patients undergoing joint surgery.

METHODS

We collected data on demographics, Health Assessment Questionnaire Disability Index (HAQ-DI), and the ROM of large joints including the shoulder, elbow, wrist, hip, knee, and ankle. Associations between the ROM of each joint and disability in the eight HAQ-DI categories were determined using receiver operating characteristic (ROC) and logistic regression analyses. ROM cut-off values of each joint for the absence of disability in each HAQ-DI category were determined using ROC curves.

RESULTS

A total of 460 patients were enrolled and analyzed in this study. Based on ROC analysis, the ROM of each joint was significantly associated with disability in each category. After adjusting for disease activity, age, and sex, shoulder abduction had the highest independent impact on disability in activity [cut-off: 139 degrees (OR: 5.26)], elbow flexion-extension in dressing [121 degrees (OR: 2.22)], wrist flexion-extension in reach [86 degrees (OR: 2.71)], hip flexion-extension in walking [126 degrees (OR: 3.42)], and knee flexion-extension in walking [134 degrees (OR: 2.97)].

CONCLUSIONS

Limited ROM of multiple joints was significantly associated with functional impairment in patients with long-standing RA. Motion in daily activity involves multiple joints, and at least two joints were independently involved in disability.