Health-related job loss is a major consequence of rheumatic diseases. In the most recent analyses (1), costs stemming from lost wages, so-called indirect costs, for all forms of arthritis were 74% of the total costs, while the direct costs of medical care were 26% of the total. This burden can be expected to increase because the portion of the US work force that is 55 years of age and older is increasing (by 2020, it will account for one-fifth of the work force) (2) and because the incidence and prevalence of many rheumatic diseases rise substantially after age 50 years. Health-related job loss also exacts a substantial toll on the quality of life of individuals, being associated with lower levels of self-esteem, life satisfaction, adaptation, perceived health status, and in those with rheumatoid arthritis, higher levels of depression and pain (3–5).
Vocational rehabilitation is one approach to addressing health-related job loss. Rheumatologists and other clinicians may wish to refer their patients with rheumatic diseases to vocational rehabilitation for help. However, there is a shortage of studies evaluating the effectiveness of vocational rehabilitation. Studies that have been done suggest that while it can be effective in helping persons with disabilities regain employment, this effect is often short-lived (6). Moreover, there are a host of obstacles associated with the task of regaining employment, including the prominence of discrimination in the hiring process (7). Further, the individual may have come to accept his or her inability to work. Providing vocational rehabilitation to persons who are at risk for job loss, but while they are still employed, may be more effective and may require a relatively brief intervention.
To evaluate the efficacy of vocational rehabilitation provided as primary prevention, we conducted a randomized controlled trial of vocational rehabilitation provided to persons with rheumatic diseases who were at risk for job loss, but while they were still working. We selected an at-risk sample to maximize the effect of the intervention and because such persons would receive priority for services. Our hypothesis was that vocational rehabilitation given to individuals in this situation would prevent job loss. Vocational rehabilitation provided to employed persons has been called job retention vocational rehabilitation (8), and we will refer to the intervention tested in this study as such.
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- SUBJECTS AND METHODS
The results of this randomized controlled trial showed that vocational rehabilitation effectively prevents job loss when it is provided to persons with rheumatic diseases who are at risk for job loss but are still employed. Job loss was both delayed and reduced in incidence among study participants who received the job retention vocational rehabilitation intervention. Such an intervention therefore has the capacity to reduce the high indirect costs associated with rheumatic diseases. Furthermore, because the intervention was relatively brief and the effect persisted over 3.5 years of followup, it should be an inexpensive intervention to deliver.
The 2 main sources for job retention intervention for persons with health impairments are agencies that provide vocational rehabilitation and employers. The federal and state governments in the US jointly fund a public vocational rehabilitation program that is available to eligible persons who have a wide variety of impairments. Services are provided at the state level. Currently, patients with disabling health conditions may obtain job retention services through the public vocational rehabilitation program, and referral of patients with health-related employment problems to this program is recommended.
In the past, relatively few persons with rheumatic diseases have received services from the public vocational rehabilitation program (22). Rheumatologists and other health care providers are the main source of referrals to vocational rehabilitation for patients with rheumatic diseases. Although some patients go through medical rehabilitation, little attention is given to employment even in this setting, as the connections between the health care and vocational rehabilitation systems that existed in previous times, such as having an on-site rehabilitation counselor, have been severed over the last decade (23). The literature shows that health care professionals do not commonly refer patients for vocational rehabilitation (24). Referral by a health care provider appears to be influential, though, since patients who were referred for vocational rehabilitation were more likely to have a successful outcome (25). Information about each state's vocational rehabilitation program can be found at www.jan.wvu.edu/SBSES/VOCREHAB.htm.
Government funding for employment support programs such as vocational rehabilitation is quite low in comparison to the funding for disability income support programs (e.g., $3 billion versus $80 billion dollars in 1995) (8). Because of low funding, persons who do not need extensive services may not be eligible for vocational rehabilitation in some state programs. This suggests that the relatively brief intervention tested in this trial may not be available in those states, even though it is likely to be highly cost effective.
Employers are the other potential source for job retention services. Employers increasingly recognize the benefit of job retention practices (8). However, intervention is generally not triggered unless a disability leave of absence occurs. In addition, only larger employers have a sufficient number of employees to make job retention intervention worthwhile, and in many cases, it is reserved for workers with occupational injuries and illnesses (8). There is only anecdotal evidence of the efficacy of job retention services provided through employers because outcome data are collected only sporadically and the information is considered proprietary in nature (8).
The efficacy of job retention intervention has previously been tested in randomized controlled trials only as a component of supported employment programs serving persons with major psychiatric disorders. In these programs, unemployed persons are placed in competitive jobs and then provided with ongoing support while they work (26). While these programs help participants gain employment (26), short job tenure has been a problem, possibly because of the particular effects of these disorders (27). In a descriptive study involving persons with various impairments who started out unemployed and then received job retention services, once they were placed in a job, 68% of the participants retained their jobs at 2 years after placement versus 50% of those who had previously received only placement services (28).
Attention to job accommodation is a primary component of job retention intervention. In data from the Health and Retirement Study, the provision of job accommodation was found to increase job tenure in the full study sample (29). In a subgroup of workers with musculoskeletal conditions, few received job accommodations; however, receipt of only 1 type of accommodation (getting help to do one's job) protected against job loss (30). Small sample size problems were noted, as well as the fact that only those with the most severe functional limitations were accommodated, and since severe limitation is a strong predictor of job loss, accommodations may have been provided too late to make a difference (30).
To our knowledge, this is the only study to evaluate the efficacy of job retention vocational rehabilitation delivered at the primary level of prevention, i.e., prior to health-related unemployment. Our outcome was job losses from all causes because we believe that poor health plays a role in most work cessation among persons with chronic diseases. However, when we examined job losses that were specifically cited as being due to health, the results paralleled those for job loss from all causes. Of the 69 job losses for which there is information, 12 in the experimental group and 21 in the control group were due to health (permanent disability) or arthritis/lupus (temporary unemployment).
Our study was conducted in one area of the US. Although it is an economically diverse area, the effect of economic conditions was not tested, since randomization was stratified by location within the area. All study participants were at some risk for job loss, but none had severe functional limitations. Therefore, the results may not be generalizable to persons living in areas with poor economic conditions or persons who have no risk for job loss or persons who have severe limitations. A more extensive intervention may be required where economic conditions are poor or for persons with severe disability. Persons at no risk may not require intervention.
The intervention was relatively brief. There were, however, previous indications of the effectiveness of 2 components of the intervention: attention to job accommodation and promotion of belief in capacity for employment (11, 29). The majority of experimental group participants (86%) thought the total of 3 hours' time was “about right.” Two counselors without special expertise in job retention interventions delivered the intervention; however, it's possible that the results would not be generalizable to the intervention as delivered by other counselors.
Future studies should test the effectiveness of the job retention intervention examined in this study upon implementation at the community level. It appears that the intervention would be inexpensive, but the actual cost-effectiveness needs to be assessed. Models for establishing connections between the health care and vocational rehabilitation systems also need to be developed and tested. Government and insurance policymakers should consider the value of early employment-support services for persons at risk for health-related job loss (23).
In conclusion, vocational rehabilitation delivered to patients with rheumatic diseases who were at risk for job loss, but while they were still employed, both delayed job loss and reduced its incidence. Such an intervention has the potential to reduce the high indirect costs as well as the personal impact of rheumatic diseases.