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- PATIENTS AND METHODS
The prevalence of work disability among persons with chronic rheumatic diseases is high. In patients with rheu- matoid arthritis (RA), work disability rates vary between 25% and 50% after 10 years of disease and increase to 90% in patients with longer disease duration (1–4). Work disability is also substantial in patients with other rheumatic conditions, such as ankylosing spondylitis (AS) (5, 6) and systemic lupus erythematosus (SLE) (7).
Costs ensuing from work disability account for a large part of the total costs associated with rheumatic conditions (8, 9). In addition to the economic consequences of work disability, the noneconomic impact on a person and his or her family may be substantial. Work disability was found to be associated with lower levels of self esteem, life satisfaction, and perceived health status and higher levels of depression and pain (10–14).
Given the large impact of work disability, work retention issues have been identified as one of the aims of the treatment of patients with rheumatic conditions (15). In the United States and European countries, vocational rehabilitation programs are being offered to patients with the goal of preventing the loss of paid employment or returning patients to work. In contrast with the many studies on factors associated with work disability (4, 16), the number of publications reporting the results of vocational rehabilitation programs is limited (17–19). The results of the few available studies, the majority of which had an uncontrolled design, indicate an overall positive effect on vocational status (18). A recent randomized controlled trial on the effectiveness of a job-retention vocational rehabilitation program (2 1.5-hour sessions) in patients with rheumatic diseases demonstrated that such an intervention delayed and reduced job loss (17). That study did not include outcome measures reflecting the impact of the vocational rehabilitation program on quality of life.
The aim of the present study was to evaluate the effectiveness of a multidisciplinary job-retention vocational rehabilitation program on the prevention of job loss and on quality of life. For that purpose, we conducted a multicenter, randomized controlled trial among patients with chronic rheumatic diseases who were in paid employment and at risk for job loss.
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- PATIENTS AND METHODS
A total of 196 patients were assessed for eligibility. Fifty-six patients were excluded because they did not meet the inclusion criteria (n = 35), refused to participate (n = 12), or could not enter the study for other reasons (n = 9).
Of the 74 patients randomized to the VR program, 10 (14%) did not take part in the intervention (protocol violations) for various reasons: hospital visits too troublesome (n = 4), hospital admission (n = 2), myocardial infarction (n = 1), new job (n = 1), and unknown (n = 2). Four of these 10 patients did not show up at any of the followup visits (lost to followup at 6 months). Over the period of 2 years, 12 participants allocated to the UC group and 13 participants allocated to the VR group withdrew from the trial (Figure 1). Reasons for withdrawal were moving out of the area (n = 5), personal and family matters (n = 7), not responding to our repeated telephone calls (n = 3), death from a heart attack (n = 1), time constraints (n = 1), loss of interest (n = 5), or other reasons (n = 3). The baseline sociodemographic and disease characteristics of the 115 patients who completed the study did not differ from those of the 25 patients who withdrew (data not shown).
The baseline sociodemographic and disease characteristics of the 140 study participants are shown in Table 1. There were no statistically significant differences in any of the characteristics between the 2 groups.
Table 1. Baseline sociodemographic and clinical characteristics of 140 patients with chronic arthritis in a randomized controlled trial comparing a multidisciplinary job-retention vocational rehabilitation program with usual care*
| ||Vocational rehabilitation (n = 74)||Usual care (n = 66)||P†|
|Age, median (range) years||43 (21–57)||44 (24–58)||0.86|
|Female||41 (55)||38 (58)||0.80|
|Living with partner||61 (82)||48 (73)||0.18|
|Diagnosis|| || || |
| Rheumatoid arthritis||34 (46)||36 (55)||0.54|
| Ankylosing spondylitis, psoriatric arthritis, or reactive arthritis||17 (23)||12 (18)|| |
| || || || |
| SLE, scleroderma||23 (31)||18 (27)|| |
|Duration of disease, median (range) months||11.0 (0–158)||19.5 (0–174)||0.60|
|Comorbidity present (Charlson index >0)||32 (43)||28 (42)||0.88|
|Education level|| || || |
| High||15 (20)||10 (15)||0.54|
| Medium||37 (50)||39 (59)|| |
| Low||22 (30)||17 (26)|| |
|Current occupational category|| || || |
| Mental demands||20 (28)||24 (36)||0.41|
| Mixed mental/physical demands||15 (20)||13 (20)|| |
| Light physical demands||20 (27)||19 (29)|| |
| Heavy physical demands||19 (25)||10 (15)|| |
|Adaptations at work due to rheumatic disease||22 (29)||15 (23)||0.35|
|Partial work disability benefit||12 (16)||11 (17)||0.94|
|Sick leave||42 (57)||35 (53)||0.66|
|Complete sick leave||21 (50)||20 (57)||0.80|
|Duration of sick leave in weeks, median (range)||16 (1–52)||18 (3–48)||0.80|
|Duration of sick leave >6 weeks||29 (39)||28 (42)||0.70|
|Duration of sick leave >40 weeks||6 (8)||2 (3)||0.17|
The use of health services during the intervention period and 2-year followup.
Over the first 6 months of the study as well as during the total 2 years of followup, no significant difference between the 2 groups was found with respect to the mean number of visits to the rheumatology nurse specialist, occupational therapist, physical therapist, social worker, psychologist, or the occupational physician (data not shown). However, patients in the UC group paid more visits to the rheumatologist in the first 6 months of the study (mean ± SD 2.8 ± 2.0) compared with the patients in the intervention group (mean ± SD 1.5 ± 1.9; P < 0.001).
Permanent job loss and increase in disability pension.
Over the total followup period, job loss occurred in both groups, predominantly in the first 12 months of followup (Table 2). All job losses were related to the rheumatic disease, and patients who lost their jobs could be classified as receiving a full work disability pension. None of the patients became unemployed for other reasons. There was no statistically significant difference in the proportion of patients with permanent job loss between the groups at any time point. Moreover, the mixed effects logistic regression model did not indicate a different trend over time between the 2 groups (test for interaction between time and intervention group: P = 0.13, test for main group effect: P = 0.86). In a secondary per-protocol analysis comparing the 64 patients who did receive the treatment in the VR group with the 66 patients in the UC group, there was no statistically significant difference in the proportion of patients with job loss between the groups at any time point or over the total followup period (data not shown).
Table 2. Job loss and increase in official disability pension (cumulative) in 140 patients with a rheumatic condition randomized to a multidisciplinary job-retention vocational rehabilitation program or usual care*
| ||Vocational rehabilitation (n = 74)||Usual care (n = 66)||P†|
|Job loss|| || || |
| 6 months||6/66 (9)||3/59 (5)||0.39|
| 12 months||12/64 (19)||11/58 (19)||0.97|
| 18 months||11/59 (19)||13/55 (24)||0.51|
| 24 months||14/59 (24)||12/53 (23)||0.89|
|Job loss or increase in official disability pension|| || || |
| 6 months||14/66 (21)||4/59 (7)†||0.02|
| 12 months||26/64 (41)||19/58 (33)||0.37|
| 18 months||26/59 (44)||23/55 (42)||0.81|
| 24 months||31/59 (53)||23/53 (43)||0.33|
With respect to the primary outcome measure job loss, there was no significant interaction between randomization group and age, diagnosis at baseline, and the presence of sick leave at baseline as performed in a logistic model. Regarding deterioration of the working situation defined as either full work disablement or institution or increase of a partial disability pension, initially more patients in the VR group than in the UC group became either fully work disabled (job loss) or, to a greater extent, partially work disabled at 6 months of followup (P = 0.02). However, after 12 months this difference disappeared. Regarding this endpoint, over the entire period there was no statistically significant difference between the 2 groups (test for interaction between time and randomization group: P = 0.09, test for main effect: P = 0.27).
In contrast with the 54 patients whose disability pension decreased, 7 patients improved (3 in the VR group and 4 in the UC group). Two patients, both in the UC group, who were partially work disabled at baseline did not receive a disability pension anymore after 12 months of followup. In addition, 4 patients who were fully work disabled became partially work disabled (3 from the VR group after 12, 18, and 24 months and 1 from the UC group after 24 months of followup), whereas 1 patient in the UC group who was fully work disabled did not receive a disability pension after 12 months of followup.
Job satisfaction, physical and mental functioning, and quality of life.
Over the total 24-month followup period, patients in the VR group showed a significantly greater improvement in fatigue, the HADS depression and anxiety subscales, and mental health as measured by the RAND 36 summary scale mental health than patients in the UC group (Table 3). Moreover, there was a trend towards a greater improvement in job satisfaction in the VR group. Pain, functional ability, and physical health did not differ between the 2 groups over time.
Table 3. Clinical outcome data at baseline and change scores from baseline in 140 patients with chronic arthritis at risk for job loss randomized to a multidisciplinary job-retention vocational rehabilitation program or usual care*
| ||Baseline, mean ± SD†||6 months, mean (95% CI)||12 months, mean (95% CI)||18 months, mean (95% CI)||24 months, mean (95% CI)||P‡|
|Job satisfaction§ (VAS 0–10)|| || || || || || |
| VR||5.57 (2.55)||0.18 (−0.92, 1.27)||1.78 (0.85, 2.70)||1.65 (0.55, 2.74)||2.00 (1.25, 2.75)||0.12|
| UC||5.53 (2.55)||0.15 (−0.80, 1.10)||0.53 (−0.48, 1.55)||0.24 (−0.96, 1.45)||0.88 (−0.33, 2.11)|| |
|Pain (VAS 0–10)|| || || || || || |
| VR||4.37 (2.31)||−0.70 (−1.40, 0.01)||−0.31 (−1.08, 0.47)||−0.43 (−1.19, 0.32)||−0.59 (−1.28, 0.09)||0.85|
| UC||4.71 (2.27)||−0.20 (−0.81, 0.41)||−0.58 (−1.28, 0.13)||−0.33 (−1.00, 0.34)||−0.42 (−1.16, 0.32)|| |
|Fatigue (VAS 0–10)|| || || || || || |
| VR||6.11 (2.42)||−0.23 (−0.92, 0.47)||−0.58 (−1.29, 0.14)||−0.48 (−1.20, 0.25)||−1.23 (−1.91, 0.54)¶||0.04|
| UC||5.43 (2.74)||0.11 (−0.53, 0.75)||−0.55 (−1.38, 0.28)||−0.05 (−0.88, 0.77)||−0.15 (−1.03, 0.73)|| |
|HAQ (0–3)|| || || || || || |
| VR||0.76 (0.50)||0.03 (−0.08, 0.13)||−0.04 (−0.15, 0.06)||0.00 (−0.11, 0.11)||−0.01 (−0.14, 0.12)||0.43|
| UC||0.83 (0.55)||−0.04 (−0.16, 0.08)||−0.07 (−0.19, 0.05)||0.08 (−0.04, 0.21)||−0.10 (−0.23, 0.03)|| |
|HADS anxiety|| || || || || || |
| VR||7.20 (4.00)||−0.30 (−1.08, 0.48)||−0.83 (−1.78, 0.11)||−0.94 (−1.87, −0.020)||−1.83 (−2.86, −0.80)¶||0.01|
| UC||6.80 (4.10)||−0.43 (−1.39, 0.54)||−0.25 (−1.37,0.89)||−0.34 (−1.53, 0.89)||−0.03 (−1.26, 1.34)|| |
|HADS depression|| || || || || || |
| VR||6.10 (3.30)||−0.02 (−1.05, 1.01)||−0.46 (−1.50, 0.57)||−0.64 (−1.71, 0.44)||−1.66 (−2.72, −0.60)¶||0.04|
| UC||5.70 (3.50)||0.28 (−0.54, 1.10)||0.02 (−0.89, 0.92)||−0.21 (−1.36, 0.93)||0.15 (−1.12, 1.42)|| |
|RAND SSC physical health|| || || || || || |
| VR||40.64 (17.66)||5.75 (−0.45, 11.95)||13.6 (7.04, 20.18)||13.78 (6.32, 21.25)||13.72 (6.73, 20.71)||0.63|
| UC||43.32 (19.03)||5.96 (0.38, 11.53)||11.7 (5.04, 18.39)||9.32 (2.75, 15.90)||11.69 (5.36, 18.02)|| |
|RAND SSC mental health|| || || || || || |
| VR||59.59 (24.08)||−1.40 (−8.40, 5.54)||5.31 (−1.99, 12.61)||11.20 (2.40, 20.06)||13.61 (6.61, 20.60)||0.01|
| UC||64.10 (23.31)||1.72 (−5.05, 8.50)||3.33 (−4.42, 11.08)||3.60 (−4.78, 12.00)||2.16 (−5.30, 9.62)¶|| |
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- PATIENTS AND METHODS
The results of this randomized controlled trial of patients with rheumatic diseases who were at risk for job loss showed that participating in a vocational rehabilitation program had no effect on remaining in paid employment. However, there was a significant effect on fatigue and mental health as compared with the usual care.
To our knowledge, this is the second randomized controlled trial investigating the effectiveness of a vocational rehabilitation program for patients with rheumatic diseases at the level of job-loss prevention. In contrast to our study, Allaire and coworkers (17) found that job loss was significantly delayed and reduced among study participants who received a job-retention vocational rehabilitation intervention.
There may be several possible explanations for this discrepancy. First, there may have been differences regarding the components and execution of the intervention. Although job accommodation, vocational counseling and guidance, education, and self advocacy were elements of the interventions in both the study by Allaire et al and the present study, the focus and intensity may have varied. Moreover, the program as provided in the study by Allaire et al was conducted in connection with an ongoing state vocational rehabilitation program, whereas in the present study the intervention was delivered in a health care setting. In the Dutch health care and social security system, the occupational physician plays an important role in the process of vocational rehabilitation. The occupational physician is linked to occupational health services, with which all companies have been legally obliged to have a contract since January 1998. However, the cooperation between occupational physicians and other health professionals, including our multidisciplinary vocational rehabilitation team, has previously been found to be an important but often troublesome element in the vocational guidance of patients with a health-related problem at work (15, 23, 30–32).
A second explanation for the difference in the results of the study by Allaire et al and our study may be that differences in the contrast between the vocational rehabilitation program and usual care may have occurred between the 2 studies. In our study, patients were directly referred for participation in the trial by the rheumatologist, who was thus aware of the working problems the patient encountered. Moreover, the rheumatologist was informed about the treatment allocation in a later stage, another factor that could have induced enhanced treatment or referrals in connection with the work problem in the UC group. Indeed, patients in the UC group initially paid more visits to the rheumatologist than patients in the VR group. The patients' participation in the trial could have made rheumatologists aware of their patients' problems at work, and if a patient was allocated to the UC group rheumatologists might have thought they needed to act on account of their patients. In addition, it is possible that patients who were allocated to the control group made an extra appointment with their rheumatologist to discuss their working problem and potential solutions. In the study by Allaire et al, the connection between regular rheumatologic care and the trial appeared to be less close (17).
A third explanation for the discrepancy between the results of the 2 trials may be that the populations studied were different. In general, patients in the study by Allaire et al were ∼5 years older, were more often women, and had better functional status as measured with the HAQ than the patients in the present study. Moreover, there may have been differences in the severity of the working problems. In our study, >40% of the patients in both groups were on sick leave at baseline, many of them longer than 6 weeks. Long-term sick leave usually indicates substantial limitations in work capacity and often precedes permanent work disability. At the time the study was conducted, the genuine setting of vocational rehabilitation plans by the occupational physician in collaboration with the patient and the employer was often postponed until the medical examination for a work disability pension was imminent at 12 months of sick leave, making job loss unavoidable. Although patients in our study were motivated to stay in the work force, with a relatively long period of sick leave, individuals may have lost confidence in their own capacity for employment and accepted their inability to work. A relatively long duration of sick leave may also have played a role in the initial excess job loss in the VR group. In our study, there were 6 patients in the VR group and 2 patients in the UC group with a sick-leave duration >40 weeks. Although this difference did not reach statistical significance, it is conceivable that the few extra patients in the VR group with a relatively long duration of sick leave at the start of the study could explain the initial excess job loss in the VR group. Overall, it could be that for those patients with a relatively long duration of sick leave, the intervention was provided too late to make a difference. Only recently the Dutch occupational health law has changed, and employees on sick leave are now seen by the occupational physician in the first 6 weeks of sick leave.
Despite the fact that our study did not demonstrate a quantitative effect regarding the prevention of job loss, a beneficial effect of the vocational rehabilitation program on fatigue and mental health was found. Fatigue has been described as a persistent disease-related threat to employment (23, 33, 34). To cope with fatigue, patients can make a number of job accommodations such as altering work hours, taking more and shorter breaks, working at home, delegating specific tasks, or making adaptations aimed at conserving energy in their personal lives to save themselves for the job. These changes take time and may not have a direct effect on the short-term working situation. Two studies (35, 36) demonstrated the relationship between fatigue and health-related quality of life as measured with the SF-36 in patients with chronic arthritis. Fatigue, general health, physical health, and mental health went hand in hand with diminished work productivity and work quality.
In addition to the beneficial effect on fatigue and mental health, a trend towards greater satisfaction with the job for patients who remained in the work force was seen. This positive trend might have reached statistical significance if the study sample had been larger. However, the considerable dropout rate in the present study, which was larger than anticipated, has negatively affected the statistical power of this study.
Although the results of the present study did not confirm the positive effect of the previous study by Allaire et al, there is ample rationale for the future development and evaluation of vocational rehabilitation programs. First, work disability remains a major problem in patients with rheumatic diseases, and second, there are a number of starting points for the design of effective interventions. For the effectiveness of job-retention vocational rehabilitation programs, it is important that patients at risk for work disability are identified in an early stage. It has been found, however, that rheumatologists often do not recognize the working problems (15, 23, 33, 37), and the same might apply to other health professionals. Currently, a number of instruments to measure work disability have become available, such as the Work Limitations Questionnaire or the Work Instability Scale (38–40). The broad implementation of such instruments in the clinical setting of rheumatologic care, especially in connection with early arthritis clinics, deserves consideration.
Apart from its timing, the connection between the health care system and vocational rehabilitation systems needs to be further developed. With respect to the Dutch situation, the role of the occupational physician as a potential participant in the vocational rehabilitation process should be explained more clearly and more communication should take place in earlier phases of vocational guidance (23).
In conclusion, a job-retention vocational rehabilitation program did not reduce the risk of job loss but improved fatigue and mental health in patients with rheumatic diseases. With the development of vocational rehabilitation interventions, the provision of these services in early phases of the work problems and the collaboration between various health care professionals including occupational physicians, employers, and the patient/employer themselves deserve special attention.