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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Objective

To study the occurrence of sick leave and to identify work characteristics related to sick leave in patients with early inflammatory joint conditions.

Methods

Patients with inflammatory joint conditions present for <12 months were included in this cross-sectional study. Approximately 85% of patients satisfying the criteria participated. Data collection included demographics, clinical characteristics, pain, physical functioning and mental health (Short Form 36), fatigue, and behavioral coping (Coping of Rheumatic Stressors questionnaire). Work characteristics included physical load, psychosocial load, job control, and support at work. Outcome was defined as sick leave for >2 weeks during the past 6 months. Multiple logistic regression analysis was conducted.

Results

Sick leave was reported by 54 (26%) of 210 employed patients, with 75% of the sick leave periods attributed to joint conditions. Of these 210 patients, 23% were classified as having rheumatoid arthritis (RA), 35% as having non-RA arthritis, and 42% as having inflammatory joint conditions without synovitis. Pain, poor physical functioning, and passive behavioral coping were related to increased sick leave, whereas diagnostic group was not. Low job control, i.e., low control over planning and pacing of activities within the job, was associated with increased sick leave (odds ratio [OR] 2.74), whereas being a supervisor (OR 0.21) and clerical work (OR 0.45) were related to reduced sick leave.

Conclusion

Substantial sick leave in the past 6 months was reported by 26% of patients with early inflammatory joint conditions. Pain, functional limitations, and fewer opportunities to determine one's work activities were associated with the occurrence of sick leave.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

In patients with rheumatoid arthritis (RA), work participation is frequently affected early in the course of disease. Reviews have shown that approximately one-third of RA patients in European cohort studies quit employment during the first 2–3 years of disease, and that 23–31% of the patients received (partial) disability payments after 2 years (1, 2). The increase in work-relevant disability has been found to be highest during the first years of RA (3–5). Compared with the general population, the prevalence of paid employment is estimated to be 4–28% lower in patients with longstanding RA, whereas the prevalence of (partial) disability pensions is 11–52% higher (1). Because only a small proportion of patients that lost employment succeeded in regaining a paid job, the prevention of work loss from the earliest phase of inflammatory joint conditions onward seems crucial (6).

In the identification of factors related to work-relevant disability in RA patients, poor physical functioning has been described consistently as a strong determinant of increased work-relevant disability (2, 7). Higher levels of pain may also play a role (7). In 2001, Chorus et al (8) showed that among RA patients, those passively coping with pain and limitations were more likely to be unemployed. Furthermore, demographic factors, e.g., older age and lower education level, are strong determinants of increased work-relevant disability (2, 7). Well-known work characteristics of increased work-relevant disability are blue-collar work and high physically demanding work (2, 7). Other work factors, such as part-time work, not supervising others, not being self-employed, low job autonomy or lack of control over work pace and activities, and lack of support at work have also been associated with increased work-relevant disability (8–12). Some of these demographic and work characteristics, e.g., education and physically demanding work, have not only been described for RA patients, but also for patients with ankylosing spondylitis (13). Finally, the clinical factors of longer disease duration, higher joint count, and higher erythrocyte sedimentation rate (ESR) may also influence work-relevant disability (2, 7).

Until now, most studies on work participation among patients with a rheumatic disease have focused on employment status, especially on work-relevant disability. Sick leave usually precedes work-relevant disability (14–16). However, insight into sick leave among workers with rheumatic diseases is limited. First, few studies have addressed sick leave, and to our knowledge, until now no study has examined the influence of disease-related, individual, and work factors on the occurrence of sick leave. Studies on sick leave due to musculoskeletal conditions have shown that sick leave was increased among workers with high physical workload, high psychosocial workload, or low social support at work (17, 18). Another study reported that demographic characteristics were more important than work-related factors in the occurrence of sick leave (19). Second, sick leave has rarely been studied in the early phase of inflammatory joint conditions, when diagnosis is not yet known and patients seek care. Insight into which factors influence sick leave in this early phase of conditions is important to support work participation from the earliest moment onward. Work characteristics are especially of interest because they may be amendable to change as part of early tertiary intervention.

In order to gain insight into the performance at work of patients seeking medical care in an early phase of disease, the aim of this cross-sectional study was to examine the occurrence of sick leave and to identify work characteristics related to sick leave in patients with early inflammatory joint conditions.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Study population.

This cross-sectional study shows the first baseline assessments of the Rotterdam Early Arthritis CoHort (REACH), an ongoing inception cohort study with 4 years of followup. REACH aims to study the etiopathogenesis, diagnostic strategies, and outcome of patients with inflammatory joint conditions for <12 months. In total, 82 general practitioners, 12 rheumatologists, and 4 rheumatologist trainees (1 university hospital, 2 general hospitals) in the greater area of Rotterdam have invited patients to participate in REACH from July 2004 onward. For general practitioners, short educational courses on the importance of early treatment of RA and early referral were organized. Physicians that agreed to participate in REACH received written information and verbal instructions on the general aims of the study and on how to send patients for inclusion in the study. Data collection includes a large array of detailed medical examination and questionnaires. When patients enter the study, they can choose to provide only limited medical data and/or self-reported questionnaires. For the present study, data were available for patients who were sent by general practitioners or rheumatologists for inclusion in the study up to July 2006. This time period was chosen to ensure followup studies would include the same study population.

General practitioners selected patients with arthritis in ≥1 joint or patients experiencing conditions in ≥2 joints without synovitis. The general practitioners determined that conditions existed for <12 months and were not due to trauma/mechanical problems. In addition, patients had to be age >16 years. During an interview by telephone and a subsequent medical examination by a rheumatologist, the inclusion criteria were verified. Patients were included if 1) joint conditions existed for <12 months with no requirement of a minimum duration; 2) they had arthritis in ≥1 joint or conditions in ≥2 joints in combination with at least 2 of the following criteria ascertained during medical examination by a rheumatologist: morning stiffness for >1 hour, bilateral compression pain in the metacarpophalangeal or metatarsophalangeal joints, symmetric presentation, positive family history, nonfitting shoes, nonfitting rings, pins and needles in fingers, or unexplained fatigue for <1 year; and 3) conditions were predominantly present in the morning and at night, and improved with movement. Patients were excluded if 1) conditions were due to trauma/mechanical problems, 2) they were age <16 years, 3) no written communication was possible in Dutch, or 4) a prior diagnosis of RA, ankylosing spondylitis, Sjögren's syndrome, systemic lupus erythematosus, or juvenile arthritis had been made by a rheumatologist before inclusion in this study.

For patients directly visiting rheumatologists, a similar verification procedure was applied. For all patients enrolled through general practitioners or rheumatologists, a rheumatologist set the diagnosis.

At the end of July 2006, 586 patients were notified by general practitioners (n = 251) and rheumatologists (n = 335) (Figure 1). In total, 166 patients did not fulfill inclusion criteria during the interview by telephone (n = 54) or during the medical examination (n = 68), or were lost before actual inclusion (n = 44). Patients lost before actual inclusion were significantly more often men compared with participants (39% versus 27%), but no differences in age existed. After inclusion, 61 (15%) of 420 patients were excluded from the current study due to incomplete data collection (5%, n = 19) or as a result of the patient's choice at onset of the study to provide only limited medical data and/or questionnaires (10%, n = 42). Age and sex of these patients were not significantly different from the study population. Therefore, 359 patients were eligible. For the present study, only patients age 18–65 years in paid employment were selected. In total, 210 (58%) of 359 patients were included. This study was approved by the ethics committees of the 3 participating hospitals. All patients gave written informed consent.

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Figure 1. Inclusion of employed patients with early inflammatory joint conditions. See Patients and Methods for additional information regarding inclusion in the Rotterdam Early Arthritis CoHort (REACH).

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Measurements.

For the variables potentially related to sick leave, we selected variables that were previously related to work-relevant disability in patients with (rheumatoid) arthritis (2, 7), and variables known to be related to sick leave in occupational populations with musculoskeletal conditions (17–19). Patients completed self-administered questionnaires on demographics, health, behavioral coping, and work characteristics. Clinical characteristics were obtained by medical examination.

Demographic characteristics.

Patients were asked about age, sex, and ethnicity. Ethnicity was defined by the country of birth of the mother if both parents were born abroad or by the country of birth of the parent that was born abroad (20). Two categories were made: Dutch citizens (no parent born abroad) and non-Dutch citizens (at least 1 parent born abroad) (20). Education was categorized, according to the highest level attained, into low (≤9 years: primary school, lower and intermediate secondary schooling, or lower vocational training), intermediate (10–14 years: higher secondary schooling or intermediate vocational training), and high (≥15 years: higher vocational training or university).

Clinical characteristics.

Patients with inflammatory joint conditions were classified into 3 mutually exclusive diagnostic groups based on the diagnosis made by a rheumatologist: 1) definite or probable RA, 2) specified or non-specified monarthritis, oligoarthritis, or polyarthritis (non-RA), and 3) inflammatory joint conditions without apparent synovitis. Swollen joint count (44 joints) was assessed and categorized into no synovitis, 1–2 swollen joints, or ≥3 swollen joints. Because diagnostic groups and swollen joint count were strongly related (r = 0.64), only diagnostic group was included in the statistical analysis. ESR (mm/hour) was measured and classified as low, intermediate, or high on the basis of tertile scores. The duration of inflammatory conditions was defined as the period between symptom onset and medical examination. Based on the median number of weeks since symptom onset, disease duration was classified as short or long. A broad range of comorbidities was ascertained, including lung disease, cardiovascular diseases, diabetes mellitus, cancer, gastrointestinal diseases, kidney diseases, diseases of the gall bladder and liver, diseases of the thyroid gland, neurologic diseases, and psychiatric disease. If 1 or more comorbidities existed, patients were classified as having a comorbid condition (yes/no).

Self-reported health and behavioral coping.

Self-reported pain and functioning were measured by 2 subscales of the Short Form 36 health survey (SF-36), bodily pain (2 items) and physical functioning (10 items), respectively (21, 22). Sum scores of these scales range from 0–100, where a higher score indicates better health. On the basis of tertile scores, bodily pain was classified into high, intermediate, and low, and physical functioning was classified into poor, moderate, and good. Similarly, mental health was ascertained by the mental health subscale of the SF-36 (5 items).

General fatigue during the past week was measured by a visual analog scale ranging from 0 (no fatigue at all) to 100 (very high fatigue), where higher scores indicate more fatigue. Fatigue was classified as low or high based on the median value of the study population.

Behavioral coping was assessed by 2 scales of the Coping of Rheumatic Stressors questionnaire. The scale “decreasing activity to cope with pain” was measured by 8 items on a 4-point scale (seldom or never, sometimes, often, very often), and similarly, the scale “pacing to cope with limitations” was measured by 10 items. Sum scores were computed, which ranged from 8–32 and 10–40, respectively. A higher sum score indicates more frequent use of the coping strategy. Both scales have good internal consistency and high test–retest reliability (23–25). Because both scales were highly correlated (r = 0.82), only “decreasing activities to cope with pain” was included in the statistical analysis, as it was considered to be the most relevant in patients with early joint conditions (24, 26).

Work characteristics.

Jobs were classified as blue collar or white collar based on job title, and full-time employment was defined as working ≥36 hours per week. Patients were asked whether they were a supervisor (yes/no) and whether they were self-employed (yes/no) (27). Physical load was assessed by questions derived from the Dutch Musculoskeletal Questionnaire on manual material handling (lifting 5 kg and/or lifting 25 kg), strenuous arm positions (working with hands above shoulder level and/or repetitive arm movements), hand-arm vibration, clerical work (prolonged sedentary work and computer work), and precision tasks (27, 28). Answers were on a 4-point scale, with the ratings seldom or never, now and then, often, and always. The answers often and always were classified as high exposure (28). Due to the low prevalence of hand-arm vibration (6%) and precision tasks (5%), these characteristics were not included in the regression analysis. Physical exertion was measured by a numeric rating scale from 0 (no effort at all) to 10 (very high effort). A score of ≥6 was classified as high physical exertion (29). Associations among the physical workload factors were low to moderate (Spearman's r range 0.05–0.42).

Questions on the psychosocial load of the job were derived from the Karasek model, in which patients are supposedly at risk for psychological strain when experiencing high job demand and low job control (30). Job demands were measured by 11 items (e.g., working fast, excessive work) on a 4-point scale (never, now and then, often, always) with a Cronbach's alpha of 0.86. Similarly, job control was measured by 6 items on skill discretion (e.g., task variety, learning new things) and by 11 items on the authority to make decisions (e.g., autonomy in executing tasks and solving problems, influence on planning) with a Cronbach's alpha of 0.92. A sum score for both dimensions was calculated and job demands and job control were defined as low or high based on the median score.

Support from colleagues was measured by a numeric rating scale ranging from 0 (no support) to 10 (high support). Support from the manager was similarly ascertained (19). On the basis of the median score, support from colleagues and the manager was classified as low or high.

Sick leave.

In The Netherlands, sick leave is defined as not being able to work in full time duty, including both complete absence from work and work activities on restricted duty due to health problems. The latter is a small proportion of all workers on sick leave. In almost all situations, the collective labor agreements require full salary payment during the first 12 months and ∼70% salary payment during the second 12 months. In this study, sick leave was measured by questions on the frequency and duration of sickness absence due to general causes in the past 6 months. For the duration of sick leave, patients reported on a 4-point scale whether they experienced no sick leave, 1–7 days, 8–14 days, or >2 weeks of sick leave. These questions have shown high specificity (91%), high sensitivity (79%), and moderate agreement with registry data (κ = 0.50 and 0.54, respectively). The questions were most accurate for patients with a sickness absence of >14 days (31). Therefore, the outcome variable of this study was defined as reporting >2 weeks of sick leave in the past 6 months.

Statistical analysis.

Logistic regression analysis was used to study the association of demographic, disease-related, and work factors with sick leave. First, univariate logistic regression was performed to investigate the association between the independent factors and sick leave. The measure of association was expressed by the odds ratio (OR) and 95% confidence interval. Characteristics with a P value ≤0.20 were selected for further investigation. Second, logistic regression analysis was performed with backward selection within 3 blocks of interrelated variables, i.e., 1) demographic variables, 2) clinical variables, self-reported health, and coping, and 3) work variables. Characteristics with a P value ≤0.20 were selected for further investigation. This second step was included in the analysis to identify those variables among interrelated variables that had the strongest association with sick leave, and therefore to reduce the number of variables studied in the final model. Third, the final multivariate logistic regression model with sick leave as the dependent variable was constructed by backward selection. Age and sex were included by default. Furthermore, independent variables with a P value ≤0.05 and variables of borderline significance with an important influence on other independent variables (>10%) were retained in the final model. Statistical analyses were performed with SPSS software, version 11.0 for Windows (SPSS, Chicago, IL).

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Table 1 shows the characteristics of 210 employed patients with early inflammatory joint conditions. Approximately 23% (n = 48) of the study population was diagnosed as having RA, 35% (n = 74) as having (non-RA) arthritis, and 42% (n = 88) as having inflammatory joint conditions without synovitis. Among those with non-RA arthritis, 27 (36%) of 74 patients had monarthritis, 39 (53%) patients had polyarthritis, and 8 (11%) patients had oligoarthritis. Patients classified as having inflammatory joint conditions without synovitis were diagnosed with arthralgia/myalgia (n = 33), inflammatory joint conditions without synovitis without further specification (n = 30), osteoarthritis (n = 16), or others (n = 9). Diagnostic group and swollen joint count were significantly associated (Spearman's r = 0.64). At least 1 comorbidity was present in 38% of patients, most often cardiovascular (n = 35) or respiratory disease (n = 16).

Table 1. Characteristics of employed patients with early inflammatory joint conditions (n = 210)*
 RA (n = 48)Non-RA arthritis (n = 74)Inflammatory joint conditions without synovitis (n = 88)
  • *

    Values are the percentage unless otherwise indicated. RA = rheumatoid arthritis; IQR = interquartile range; ESR = erythrocyte sedimentation rate.

Demographic factors   
 Age, mean ± SD years46 ± 1144 ± 1044 ± 10
 Women775881
 Non-Dutch origin232319
 Education   
  Low484338
  Intermediate334131
  High191631
Clinical factors   
 Disease duration, median (IQR) weeks16 (19)15 (17)19 (19)
 Swollen joint count, median (IQR) (44 joints)3.0 (7.0)2.0 (2.3)0 (0)
 ESR, median (IQR) mm/hour21 (27)17 (30)8 (9)
 Comorbidity353741
Self-reported health (range 0–100)   
 Bodily pain, mean ± SD40 ± 2043 ± 2149 ± 18
 Physical functioning, mean ± SD57 ± 2460 ± 2669 ± 22
 Mental health, mean ± SD73 ± 1871 ± 1671 ± 17
 Fatigue, median (IQR)43 (46)58 (42)56 (39)
Behavioral coping, mean ± SD   
 Decreasing activity to cope with pain (range 8–32)15.1 ± 4.815.8 ± 4.714.0 ± 4.3
 Pacing to cope with limitations (range 10–40)21.3 ± 6.921.4 ± 6.018.7 ± 6.2
Work factors   
 General features   
  Blue-collar job545049
  Supervisor171521
  Self-employed15159
  Part-time employment (<36 hours/week)634957
 Physical load   
  Frequent manual handling of materials232618
  Frequent strenuous arm movements626449
  Frequent hand-arm vibration8111
  Prolonged clerical work323838
  Frequent precision tasks6101
  Physical exertion, median (IQR) (range 0–10)6.0 (5.0)6.0 (5.0)6.0 (5.0)
 Psychosocial load, median (IQR)   
  Job demands (range 0–33)12 (5.0)13 (6.0)13 (6.0)
  Job control (range 0–51)32 (17)31 (14)31 (14)
 Support, median (IQR) (range 0–10)   
  From colleagues7.0 (2.8)7.0 (3.0)7.0 (2.0)
  From managers7.0 (7.0)7.0 (3.0)7.0 (3.0)
Sick leave >2 weeks352719

In total, 134 (64%) patients reported ≥1 period of sick leave in the past 6 months. Sick leave for 1–7 days was reported by 58 (28%) patients, 22 (10%) patients reported 8–14 days of sick leave, and 54 (26%) patients reported >2 weeks of sick leave. Among the 54 patients with >2 weeks of sick leave, 75% attributed their sick leave to their joint conditions, and another 15% reported their joint conditions as a contributing factor.

Table 2 shows that in univariate logistic regression, patients with RA more often experienced sick leave compared with patients with inflammatory joint conditions without synovitis (OR 2.29). Increased pain, reduced physical functioning, reduced mental health, and more fatigue were associated with increased sick leave. Lower educated patients more often reported sick leave than higher educated patients. Blue-collar work (OR 2.78) and low job control (OR 3.32) increased the likelihood of sick leave, whereas being a supervisor (OR 0.21) and prolonged clerical work (OR 0.46) were associated with less sick leave. The following characteristics had little or no influence on sick leave in the univariate analysis: ethnicity, disease duration, part-time employment, job demands, and support from the manager (Table 2). Additionally, swollen joint count was not associated with sick leave (data not shown).

Table 2. Associations between demographic, disease, and work characteristics and sick leave in patients with early inflammatory joint conditions in a univariate logistic regression analysis*
Independent characteristicsSick leave
OR95% CI
  • *

    OR = odds ratio; 95% CI = 95% confidence interval; RA = rheumatoid arthritis; ESR = erythrocyte sedimentation rate.

  • P ≤ 0.05.

  • P ≤ 0.20.

Demographic  
 Age, years1.020.99–1.05
 Sex, male vs. female1.560.80–3.03
 Ethnicity, non-Dutch vs. Dutch origin1.060.50–2.23
 Education  
  High1.00 
  Intermediate6.471.82–23.1
  Low7.372.11–25.7
Clinical  
 Diagnostic group  
  Inflammatory joint conditions, no synovitis1.00 
  Non-RA arthritis1.580.75–3.30
  RA2.291.04–5.07
 ESR, mm/hour  
  Low (1–7)1.00 
  Intermediate (8–20)0.920.38–2.22
  High (>20)2.170.98–4.81
 Disease duration, long vs. short (median 15 weeks)1.010.98–1.03
 Comorbidity, yes vs. no2.001.07–3.76
Self-reported health  
 Bodily pain  
  Low (≥52)1.00 
  Moderate (39–51)4.411.40–14.0
  High (≤38)16.55.39–50.4
 Physical functioning  
  Good (≥76)1.00 
  Moderate (54–75)1.540.60–3.98
  Poor (≤53)7.783.35–18.1
 Mental health  
  Good (≥81)1.00 
  Moderate (65–80)1.800.71–4.53
  Poor (≤64)4.842.01–11.7
 High fatigue (≥61)1.881.00–3.56
Behavioral coping  
 Decreasing activity to cope with pain (range 8–32)1.221.13–1.32
 Pacing to cope with limitations (range 10–40)1.131.07–1.19
Work  
 Blue-collar job2.781.44–5.37
 Supervisor0.210.06–0.71
 Self-employed0.480.16–1.47
 Part-time employment (<36 hours/week)1.400.74–2.63
 Frequent manual handling of materials1.980.98–4.00
 Frequent strenuous arm movements1.860.96–3.58
 Prolonged clerical work0.460.23–0.92
 High physical exertion (≥6.0)1.550.83–2.88
 High job demands (≥13)1.200.65–2.24
 Low job control (≤30)3.321.72–6.41
 High support from colleagues (≥7.0)0.530.28–1.01
 High support from manager (≥6.0)1.490.80–2.80

Diagnostic group, ESR, self-reported health, and coping were all associated with sick leave, but also had substantial interrelationships. When adjusted for each other, bodily pain and physical functioning were associated with the occurrence of sick leave, whereas diagnostic group, ESR, mental health, and fatigue were not.

Table 3 shows that in the final multivariate logistic regression analysis, higher pain intensity (OR 4.11), poor physical functioning (OR 3.76), and passive coping by decreasing activity to cope with pain were associated with an increased likelihood of sick leave. A 1 SD increase in passive coping with pain was related to 1.77 times higher odds of sick leave. Low job control was associated with increased sick leave (OR 2.74), whereas being a supervisor (OR 0.21) and clerical work (OR 0.45, P = 0.08) were related to reduced sick leave. Education level was not associated with the occurrence of sick leave when other factors were taken into account. The number of comorbidities was not associated with sick leave (data not shown). In this multivariate analysis, blue-collar work was not included due to its relationship with education level and physical workload.

Table 3. The influence of demographic, disease, and work characteristics on sick leave in patients with early inflammatory joint conditions in a multivariate logistic regression analysis*
Independent characteristicsSick leave
OR95% CI
  • *

    OR = odds ratio; 95% CI = 95% confidence interval.

  • P ≤ 0.05.

  • P = 0.08.

Age, years1.020.99–1.06
Sex, male vs. female2.711.10–6.70
Comorbidity, yes vs. no2.571.08–6.08
Bodily pain  
 Low (≥52)1.00 
 Moderate (39–51)2.960.85–10.3
 High (≤38)4.111.10–15.4
Physical functioning  
 Good (≥76)1.00 
 Moderate (54–75)1.580.51–4.88
 Poor (≤53)3.761.24–11.4
Decreasing activity to cope with pain (range 8–32)1.131.02–1.25
Supervisor0.210.05–0.88
Clerical work0.450.18–1.11
Low job control (≤30)2.741.16–6.94

When interaction terms for the work characteristics and the level of pain, functioning, and diagnostic group were added to the model, no significant interaction effects were found. Therefore, the observed associations between the work characteristics and sick leave did not differ significantly among patients with different levels of pain or functioning, or among diagnostic groups.

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

One (26%) of 4 patients seeking medical care with early inflammatory joint conditions already experienced substantial sick leave, i.e., >2 weeks during the past 6 months. Self-reported pain, poor physical functioning, and passive behavioral coping were related to an increased occurrence of sick leave, whereas diagnostic group was not. Low job control increased the likelihood of sick leave, and being a supervisor and clerical work were associated with reduced sick leave.

In this study, 26% of patients with early inflammatory joint conditions reported >2 weeks of sick leave in the past 6 months. Similarly, in a longer period of 12 months, Zirkzee et al (15) described sick leave for >2 weeks in 41% of patients with early arthritis. Sick leave was also more frequently observed among workers with arthritis and related joint disorders than in a comparison group in the US (32). To our knowledge, this is the first study examining the factors associated with sick leave in an early phase of inflammatory joint conditions. Previous studies have shown that pain, functioning, behavioral coping, and work characteristics play an important role in work-relevant disability after progression of the disease (2, 7, 8). The present study indicates that these factors are already related to the performance at work in patients with early inflammatory joint conditions, and therefore offer opportunities for early intervention. Our findings also suggest that, at least in an early phase of inflammatory joint conditions, the associations between work characteristics and sick leave do not differ across diagnostic groups.

Pain and physical functioning, which have been described to be notably affected in patients with early inflammatory joint conditions (33), were strongly associated with sick leave. Remarkably, diagnostic group had little influence on sick leave when other factors, notably pain and functioning, were taken into account. The diagnostic group reflects the underlying disease, whereas self-reported pain and functioning may reflect both the underlying disease and the patients' experience of the symptoms, which is influenced by demographic and psychosocial factors (33). The importance of self-reported pain and functioning in relation to sick leave was further supported by the observation that ESR and swollen joint count were not associated with sick leave (data not shown).

Low job control, i.e., low control over the organization and planning of activities in the job, was related to increased sick leave. This was in agreement with previous studies showing the influence of control over the pace and the activities of work (9) and work autonomy (12) on work-relevant disability. In a focus group, patients with RA stated that the opportunity to plan work activities and the freedom to spread the work out were, among others, factors that a patient with RA needs to continue working (34). Similarly, interviews with RA patients showed that important adaptations made to keep working included control over what work was done on a given day and control over work hours (35). Patients with longstanding disease have described that flexible work arrangements are a helpful strategy to continue working, because flexibility allows workers to consider their arthritis when planning their tasks and work day. This improves both the patient's well-being and their performance at work (36). The relationship between job control and work participation also reflects a general mechanism, because low job control has been related to the persistence of arm, neck, and shoulder conditions (37) and to higher sickness absence in the general work force (38). Therefore, it is not known whether our finding reflects a mechanism in the general work force or whether job control is especially important in patients with inflammatory joint conditions. Clerical work was of borderline significance for reduced sick leave. Clerical work was not associated with job control, but was inversely related to measures reflecting physical workload. Because earlier studies showed that high physical workload is a marker of work-relevant disability (7), our findings are in agreement with the literature. Work characteristics are known to be a reflection of education level, which was also found in our study; i.e., 55% of the low educated patients reported low job control, whereas only 21% of the high educated patients reported low job control. We found that education level was no longer related to sick leave if work characteristics were taken into account. This suggests that work factors brought about the differences in sick leave among patients with different education levels.

In this cross-sectional study, the baseline data of an ongoing inception cohort study (REACH) were used. Because the prevalence of inflammatory joint conditions in the general population is unknown, little insight exists into potential selection processes during the referral of patients by physicians to this inception cohort study. However, selection bias probably did not influence our findings to a great extent, because it is unlikely that physicians selected patients on the basis of work characteristics. Furthermore, due to the response of 85% after inclusion, we are confident that a response bias has not influenced the results of this study to a large extent. Sick leave was measured by self-reported questions because registry data were not available. This is a drawback, but the self-assessment of sick leave has shown moderate agreement between questionnaire and registry data and was most accurate for sickness absence for >2 weeks in the past 6 months (31). Finally, due to the cross-sectional design of this study, no inferences on causal relationships can be made. Cause and effect are especially difficult to discern for the characteristics decreasing activity to cope with pain and job control.

This study showed that an important proportion of patients seeking care with early inflammatory joint conditions have already experienced sick leave. Pain and physical limitations, which are targeted during medical treatment, were strongly related to the occurrence of sick leave. Our findings suggest that work characteristics already relate to early signs of loss of performance at work, as characterized by sick leave. Job control, and to a lesser extent clerical work, might be amendable to change. Therefore, they might offer opportunities for early adaptations of the job to support work participation from disease onset onward, in addition to medical treatment (17).

In conclusion, 26% of patients seeking care with early inflammatory joint conditions reported substantial sick leave in the past 6 months. Pain, functional limitations, and fewer opportunities to determine one's work activities were associated with the occurrence of sick leave.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Ms Geuskens had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study design. Geuskens, Hazes, Barendregt, Burdorf.

Acquisition of data. Geuskens, Hazes.

Analysis and interpretation of data. Geuskens, Hazes, Burdorf.

Manuscript preparation. Geuskens, Hazes, Barendregt, Burdorf.

Statistical analysis. Geuskens, Hazes, Burdorf.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES
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