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- PATIENTS AND METHODS
Labor force participation (LFP) is recognized as an important outcome measure when assessing the impact of rheumatoid arthritis (RA) (1). An increasing number of studies on this issue have been published over the past years (2–5). Different consequences of the inability to perform paid work have been explored, including loss of social contacts resulting in reduction of quality of life and lower self esteem (6). All these studies on LFP in RA, except for 1 from Slovakia in 1984 (7), were performed in the United States and in Western European countries having high employment rates, high quality of health care provision, and stable social security systems. Because differences in labor market conditions and social security systems are likely to influence the possibilities for LFP, the data from these studies cannot be extrapolated to Eastern European countries. No data have been published from this geographic region in recent years, during which major economic processes of decentralization and privatization took place. Employment in people with RA or ankylosing spondylitis was recently shown to be significantly lower under less favorable labor market conditions in a study comparing former East and West German states (5). Previously, we showed that patients with RA in Lithuania had worse physical function and higher disease activity when compared with age- and sex-matched patients with RA in Norway (8). In the present study, we extensively evaluated working status in patients with RA in Lithuania; characteristics of those who are work disabled were compared with those who are employed; and the associations with quality of life were estimated. In addition, the influence of the transition to a free-market economy in 1990 on LFP was analyzed.
- Top of page
- PATIENTS AND METHODS
Our study is the first to investigate LFP in RA in 1 of the former socialistic East European countries having experienced important economic changes during the last decade. All other studies on LFP in RA examined North American or Western European communities. Cross-sectional employment in these countries ranged from 42% in a publication from 1995 (15) to 61% in a publication from 2000 (4). In longitudinal studies of RA patients, an employment rate of only 36% of initially employed patients was reported in 1987 from a Finnish inception cohort after 8 years of followup (16), compared with a favorable employment rate of 58% in 1998 in a study from the US after 7 years of followup (17) and 60% in a recent publication from the UK after 5 years (18). Data on prevalent work disability range from 48% to 63%, higher figures being noted in later reports (15, 19, 20). Longitudinal studies showed that ∼30% of the patients had become work disabled in the first 2 years of disease (2); another publication found 44% had become work disabled after 10 years, with the most important withdrawal in the first 2 years (21, 22). Overall, the employment perspectives of patients with RA certainly did not improve over time. This was also clearly shown in a study by Barrett et al (2) who compared 2 matched cohorts of patients with 4-years' interval and showed the work disability rates to be higher in later cohort.
Within the limits of comparability of studies on LFP, the impact of RA on work status is more pronounced in Lithuania. The unfavorable result could be partly explained by differences in health care provision, resulting in more severe disease, but also in organization of the social security system (8). The influence of the labor market was already shown by Zink et al (5), demonstrating an adjusted risk ratio of 2.38 for premature termination of employment among patients from the former East German states when compared with patients from the former West German states. At the time of this study, unemployment was 20% and 11% in these regions, respectively. Our study is the first to describe the direct influence of economy transition on work disability, with an increase in the risk by 2.75. The exact figures for unemployment rate in years before economy transition in Lithuania are not available, but it is known that during the period 1994–1999 it increased 1.5 times and was 16.7% at the time of the study. This previously overlooked factor might apply to several countries and should not be neglected by health professionals and policy makers when planning scenarios for health care provision.
Absence at paid work has not yet received much attention in the literature (7, 23). This is surprising because sick leave is often the forerunner of permanent work disability. Mau et al (23) reported 76% of RA patients with early disease took sick leave and the length of sick leave was 5 times longer when compared with data from a health insurance register. In our study among patients with longer disease duration, the average number of days of sick leave was somewhat more favorable, probably because patients with the most severe disease had already left the labor force because of work disability.
When studying the determinants of LFP, our results fit well with the findings of other studies (3, 24–31). Similar to Western societies, higher age (30, 31), longer disease duration (24), lower educational level (25, 30), manual jobs (3, 21), and worse physical function (26, 27) were associated with higher work disability. Interestingly, we did not find higher disease activity measured by DAS-28 to be associated with loss of work. Likely, variance in disease activity is captured in physical functioning as measured by the MHAQ. We find support of this hypothesis in the study by Drossaers-Bakker et al (32), who reported the DAS to show a variable course over 12 years of followup, but was the main determinant of the HAQ when entered in a multivariate analysis.
Similar to the findings of a recent Dutch study by Chorus et al (4), Lithuanian work disabled patients reported lower values on the physical domains of the SF-36, but also for emotional role and mental health. It is of note that the Lithuanian patients experienced worse quality of life for every domain compared with their Dutch counterparts.
Our study has some limitations. First, the relatively low response rate of 58% might have influenced the composition of the studied population. Patients my not participate for various reasons, from being too sick to being too busy with daily occupation because of relatively light disease. Second, the cross-sectional design does not allow adjusting for dynamic fluctuations of the disease and for societal processes. Third, the study is lacking information on reentering the labor force after leaving the job due to RA. Straaton et al (33) showed that up to 24% are able to return to permanent employment. Finally, the comparison of our data with the results of other studies is hampered because of the heterogeneity of the patients included, but also because most studies failed to adjust the figures on work status for age and sex.
Within the limits of the study, employment perspectives in patients with RA in Lithuania are unfavorable and even worse after the transition to a free-market economy. Comparable with studies in Western countries, worse physical function is strongly related to work disability, and work-disabled patients experience lower quality of life. Whether the more unfavorable situation of the Lithuanian patients is attributable to differences in access to and quality of health care, resulting in more important impairment of physical function, or to differences in social security systems or even to economic factors cannot be concluded from the study, but should not be neglected as possible explanatory factors.