Vocational rehabilitation programs for individuals with chronic arthritis.

PURPOSE OF REVIEW: To summarize recent literature on vocational rehabilitation interventions in patients with chronic arthritis. RECENT FINDINGS: The current literature shows that the prevalence of work disability, including work cessation, sick leave, and any other restriction in the work status among patients with chronic arthritis, is substantial. In some studies, a trend towards a decline in work disability in chronic arthritis is seen, possibly reflecting improvements in medical treatment. The proof of effectiveness of comprehensive vocational rehabilitation interventions aimed at individuals in various stages of work disability is scanty. With prolonged sick leave being a major determinant of job loss, interventions are nowadays developed that specifically address patients with chronic arthritis at a stage in which sick leave occurs, with promising results. Economic evidence is limited, but savings on productivity are likely to outweigh the costs of an effective intervention. SUMMARY: Despite advances in medical treatment, work disability among individuals with chronic arthritis is substantial. Although the (cost-)effectiveness of interventions in patients with established work disability is unclear, the results of studies on interventions employed in the early stages of threatened work ability point to a favorable effect.

Sick leave and work disability in patients with early arthritis.

We studied the occurrence of sick leave and work disability, the presence of workplace adaptations and the usage of professional guidance related to working problems in patients with early arthritis. Inclusion criteria were arthritis symptoms of less than 2 years duration and a paid job at the time of diagnosis. Assessments were done in connection with an early arthritis clinic (EAC) at entry into the cohort and 12 months thereafter by means of a questionnaire comprising questions on sick leave (absenteeism from work reported to the employer), work disability (receiving a full or partial work disability pension), unemployment, work adaptations and professional guidance related to working problems. Fifty-seven of the 69 participants (83%) had an arthritis symptom duration of <6 months. The number of patients with sick leave due to arthritis in the past 12 months decreased from 28 (41%) at study entry to 18 (26%) after 12 months of follow-up. The number of patients receiving a work disability pension increased from 5 (7%) at study entry to 13 (19%) after 12 months of follow-up (10 partial and 3 full). Sick leave in the 12 months before study entry appeared to be the most important predictor of the institution or increase in a work disability pension (odds ratio, 16.1; 95%CI, 1.8-142.8). Between study entry and follow-up, the number of patients with workplace adaptations increased from 20 (29%) to 28 (42%), whereas the number of patients receiving vocational guidance decreased from 48 (70%) to 36 (52%). In patients with early arthritis and a paid job, arthritis-related sick leave was common and occurred in part before patients entered the EAC and a diagnosis was made. About 20% of the patients became permanently work disabled, with partial work disability being more common than full work disability. Considerable proportions of patients received workplace adaptations and professional guidance with working problems.

Cost-utility analysis of a multidisciplinary job retention vocational rehabilitation program in patients with chronic arthritis at risk of job loss.

OBJECTIVE: To estimate from a societal perspective the cost-utility of a multidisciplinary job retention vocational rehabilitation program compared with usual care in patients with chronic rheumatic diseases at risk of job loss. METHODS: Patients (n = 121) were randomly assigned to either the vocational rehabilitation program or usual outpatient care initiated by the treating rheumatologist. Followup lasted for 2 years. Program costs were estimated using time registrations and other societal costs using quarterly cost questionnaires filled out by the patients. To estimate quality-adjusted life years, utility was assessed using the EuroQol classification system, EuroQol rating scale, Short Form 6D, and Time Trade-Off. RESULTS: As part of the vocational rehabilitation program, patients on average had a total of 7.1 consultations and the total time spent by the multidisciplinary team was 12.7 hours per patient. Program costs were estimated at euro1,426, of which approximately 20% were time and travel costs incurred by the patients. No significant differences were found in other health care consumption, productivity, or quality-adjusted life years. Program costs were outweighed by total savings on other health care and nonhealth care costs, but not significantly. CONCLUSION: From a societal perspective, it remains unclear whether the program reduces or increases total costs. Further research on effective vocational rehabilitation is warranted, with special attention to early detection of work problems and the collaboration between health care and vocational rehabilitation services.

Sick leave as a predictor of job loss in patients with chronic arthritis.

OBJECTIVES: To study the occurrence and duration of sick leave as potential risk factors for permanent job loss after 24 months among 112 individuals with chronic arthritis and a disease related problem at work. METHODS: Data collection was embedded in a multicentre randomised controlled trial in which the cost-effectiveness of a multidisciplinary job retention vocational rehabilitation programme for employees with chronic arthritis and a disease related problem at work was compared to usual outpatient care. Sick leave (complete or partial) was defined as absenteeism reported to the employer and permanent job loss as receiving a full work disability pension or unemployment. The association between sick leave at baseline and job loss after 24 months was investigated by multivariate logistic regression analysis, including those variables that were univariately significantly associated with job loss after 24 months. RESULTS: At baseline, 60 of the 112 subjects (54%) were on sick leave, with a mean duration of 18.7 weeks, in half of these patients the sick leave was complete. After 24 months, 26 of the 112 patients (23%) had lost their job. The presence of complete sick leave (OR 4.74, 95% CI 1.86-12.07) and the depression score of the hospital anxiety and depression scale (OR 1.18, 95% CI 1.02-1.36) were significantly and independently associated with job loss after 2 years follow-up. CONCLUSION: The occurrence of complete sick leave was found to be an independent risk factor for job loss in patients with chronic arthritis who have a disease related problem at work.

Randomized comparison of a multidisciplinary job-retention vocational rehabilitation program with usual outpatient care in patients with chronic arthritis at risk for job loss.

OBJECTIVE: Work disability is a major consequence of inflammatory rheumatic conditions. Evidence regarding the effectiveness of interventions aimed at the prevention or reduction of work disability in rheumatic diseases is limited. We conducted a randomized controlled trial to investigate the effectiveness of a multidisciplinary job-retention vocational rehabilitation (VR) program in patients with a rheumatic condition who were at risk for job loss. METHODS: A total of 140 patients with a chronic rheumatic condition were randomly assigned to either a multidisciplinary job-retention VR program (n = 74) or usual outpatient care (UC) (n = 66). Patients in the VR group were assessed and guided by a multidisciplinary team, whereas patients in the UC group received care as initiated by their rheumatologist, supplemented with written information. The main outcome measure was the occurrence of job loss (complete work disability or unemployment); additional outcome measures included job satisfaction, pain, functional status, emotional status, and quality of life. RESULTS: There was no difference between the 2 groups regarding the proportion of patients having lost their job at any time point, with 24% and 23% of the patients in the VR and UC groups, respectively, having lost their job after 24 months. Over the total period of 24 months, patients in the VR group had a significantly greater improvement of the fatigue visual analog scale and of emotional status (all P values < 0.05). CONCLUSION: A job-retention VR program did not reduce the risk of job loss but improved fatigue and mental health in patients with chronic rheumatic diseases at risk for job loss.

Vocational rehabilitation in patients with chronic rheumatic diseases: a systematic literature review.

OBJECTIVE: To describe the effectiveness of vocational rehabilitation programs for patients with chronic rheumatic diseases by means of a systematic review of the literature. METHODS: Data were obtained by a computer-aided and manual search of the literature from 1980 until May 2001. Vocational rehabilitation programs had to be clearly defined interventions specifically aimed at having patients with rheumatic diseases reenter or remain in the work force. The vocational rehabilitation programs had to be executed by one or more health professionals. Outcome of the intervention had to be described in terms of vocational status (work disability, sick leave, job modification, paid occupation, retraining). RESULTS: Six studies were identified. All were uncontrolled studies. Follow-up periods ranged 2-84 months. Five of six vocational rehabilitation programs consisted of multidisciplinary intervention and 15% to 69% of the patients successfully returned to work. CONCLUSIONS: Although 5 of 6 studies showed a marked positive effect of vocational rehabilitation on work status, proof of the benefit of these interventions is limited, mainly due to methodologic differences and shortcomings. RELEVANCE: Work disability is a major consequence of the disease in patients with rheumatic conditions. More and more attention is being paid to preventing disability and promoting return to work. Knowledge regarding the effectiveness of vocational rehabilitation programs is insufficient. Semin Arthritis Rheum 32:196-203.