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Disability Work among Argentinean Patients with Rheumatoid Arthritis

January 2012
Open Journal of Rheumatology and Autoimmune Diseases 02(03)

January 2012
02(03)

DOI:10.4236/ojra.2012.23014

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CC BY 4.0

Authors:

Maria Natalia Tamborenea

Hospital Bernardino Rivadavia

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Objective: 1) To analyze the prevalence of Work Disability (WD) in RA Argentinian patients who are attending at the National Rehabilitation Service (NRS); 2) To measure general, socioeconomics and disease characteristics in this popu-lation; 3) To characterize the associated factors of work disability in this group. Methods: Design cross section obser-vational study. RA patients attending the NRS were included in consecutive form. Clinical, demographic and radio-logical data were collected. All patients answered about their employment status. WD was defined if the work status was unemployed due to RA, retirement prior to the normal age, or disabled pension. Comparing analysis among pa-tients with and without paid work was done. Housewives, retired patients and students were excluded from the compar-ing analysis. Results: Three hundred and eleven patients were included (n = 311). The prevalence of WD was 44.05% (n = 137). During the study 85 (27.3%) patients were in paid employment, 48 (15.3%) were retired, 39 (12.5%) were housewives, and 2 (0.6%) patients were students. Factor associated to WD were female sex, more than 5 years of dis-ease duration, have health insurance, education beyond high school, and greater functional limitation: HAQ > 1 and function class 3 -4. In the multivariable logistic regression model female sex was a significant and independent predic-tor of WD. Having health insurance; and more than high school education were protector factors of WD in this model. Conclusion: WD prevalence in this sample was higher than other countries. Socioeconomics factors more than diseases factors were significant predictors of productivity loss in this sample.

. Comparative analysis among patients with and without paid work (n = 223).

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Open Journal of Rheumatology and Autoimmune Diseases, 2012, 2, 73-76

doi:10.4236/ojra.2012.23014 Published Online August 2012 (http://www.SciRP.org/journal/ojra) 73

Disability Work among Argentinean Patients with

Rheumatoid Arthritis

Tamborenea Maria Natalia, Silvia Moyano Caturelli, Jackeline Spengler, Grisel Olivera Roulet

Servicio Nacional de Rehabilitación (SNR), Buenos Aires, Argentina.

Email: nataliatamborenea@hotmail.com

Received March 20th, 2012; revised April 27th, 2012; accepted May 9th, 2012

ABSTRACT

Objective: 1) To analyze the prevalence of Work Disability (WD) in RA Argentinian patients who are attending at the

National Rehabilitation Service (NRS); 2) To measure general, socioeconomics and disease characteristics in this popu-

lation; 3) To characterize the associated factors of work disability in this group. Methods: Design cross section obser-

vational study. RA patients attending the NRS were included in consecutive form. Clinical, demographic and radio-

logical data were collected. All patients answered about their employment status. WD was defined if the work status

was unemployed due to RA, retirement prior to the normal age, or disabled pension. Comparing analysis among pa-

tients with and without paid work was done. Housewives, retired patients and students were excluded from the compar-

ing analysis. Results: Three hundred and eleven patients were included (n = 311). The prevalence of WD was 44.05%

(n = 137). During the study 85 (27.3%) patients were in paid employment, 48 (15.3%) were retired, 39 (12.5%) were

housewives, and 2 (0.6%) patients were students. Factor associated to WD were female sex, more than 5 years of dis-

ease duration, have health insurance, education beyond high school, and greater functional limitation: HAQ > 1 and

function class 3 - 4. In the multivariable logistic regression model female sex was a significant and independent predic-

tor of WD. Having health insurance; and more than high school education were protector factors of WD in this model.

Conclusion: WD prevalence in this sample was higher than other countries. Socioeconomics factors more than diseases

factors were significant predictors of productivity loss in this sample.

Keywords: HAQ; Work Disability; Rheumatoid Arthritis

1. Introduction

Rheumatoid Arthritis is a chronic disabling condition that

may affect the lives of individual patients in many ways.

One of most important outcomes may be work disability

[1,2].

Participation in paid employment is a major life role

for most adults. People with arthritis can expect to be

employed fewer years than the general population [3,4]

and withdrawal from paid employment, or work disabil-

ity, is a relatively common outcome of RA. It results in

lost income for the patient and less productivity for soci-

ety [5].

Research into WD has been reported from USA and

from European countries, rates of this outcome reported

range from 22% to 85% [6].

Variations in estimated rates are likely due to differ-

ences in methods, subject selection, time, available treat-

ments and definitions of work disability.

National Rehabilitation Service (NRS) in Argentina,

evaluate patients with Rheumatoid Arthritis diagnosis

who request Disability Certification according to 22431

law. This law establishes the conditions for grant the

disability certificate. It is a public document issued by an

interdisciplinary team that performs a biopsychosocial

evaluation.

The National Disability Certificate is the admission

key to the health system and the principal tool for the

access to complete coverage of medication and rehabili-

tation.

In this study we analyze the prevalence of WD in RA

patients who are attending at the National Rehabilitation

Service (NRS) in Argentina and determine the associated

factors to this outcome in this group.

2. Patients and Methods

RA patients are attending at the NRS for tramit the Na-

tional Disability Certificate. They ask for this certificate

in voluntary way and the population are from Buenos

Aires province and rest of the all country.

From May 2008 to August 2008 RA patients were in-

cluded in consecutive form in this cross section observa-

tional study.

Disability Work among Argentinean Patients with Rheumatoid Arthritis

Clinical, demographic and radiological data were col-

lected.

All patients answered about their employment status.

The first question asked “main form of work” was un-

employed, paid work, retired, housework, student or dis-

abled.

WD was defined if the work status were unemployed

due to RA, retirement prior to the normal age or disabled

pension.

We analyzed the following characteristics about the

disease: time of disease evolution, rheumatoid factor,

functional class, radiographic erosions, HAQ-A and DAS

28 results.

For assess the association among disease characteris-

tics and work status, were excluded for the analysis

housework, students and retired patients.

3. Statistical Analysis

The sample was characterized using descriptive proce-

dures.

To analyze categorical variables X2 were used and

Student’s t-test and Mann-Whitney test for continuous

variables.

The main analysis was multivariable logistic regres-

sion to assess the roles of independent variables as pre-

dictors of work disability.

The logistic regression model was constructed with the

following independent variables sex, education level,

health insurance, years of disease evolution, functional

class, anatomic class, HAQ-A and DAS28 results. We

calculated odds ratios and 95 % CIs. p values < 0.05 was

considered significant.

4. Results

Three hundred and eleven patients were included (n =

311). The prevalence of WD was 44. 05% (n = 137).

Women were 87% (n = 271) of the patients, the sam-

ple was predominantly middle aged (mean age 54 years),

the median time of disease evolution was 8 (4 - 15) years.

Around 75.8% (n = 236) had some type of health insur-

ance.

The 68.8% (n = 214) of the sample have education

beyond high school.

The HAQ-A score was bigger than 1 in 82.2% (n =

256) of the patients and the DAS28 was more than 3.2 in

the 83.3% (n = 259) of the sample. Function class was 3

or 4 in 199 patients (64.2%) and radiographies erosions

were present in 234 (76%) patients. 91% (n = 285) of the

population was positive for rheumatoid factor test (Table

1).

During the study 85 (27.3%) patients were in paid em-

ployment, 48 (15.3%) were retired, 39 (12.5%) were

housewives, and 2 (0.6%) patients were students (Table

1).

In the comparing analysis among patients with and

without paid work, were excluded housewives, retired

patients and students. To avoid expected retirement-re-

lated work cessation, subjects in our analysis were lower

than 65 years old, remaining 223 patients for this analy-

sis.

There were statistical significant differences when

comparing characteristics among patients with and with-

out WD, included gender (p: 0.001), more than 5 years of

disease duration (p: 0.013), have health insurance (p:

0.005), education beyond high school (p: 0.000), and

greater functional limitation: HAQ-A > 1 (p: 0.017) and

function class 3 - 4 (p: 0.026) (Table 2).

In the multivariable logistic regression model female

gender was a significant and independent predictor of

WD p: 0.004 OR IC 95% 3.2 (1.46 - 7.01). Having health

insurance p: 0.01 OR IC 95% 0.42 (0.21 - 0.81); and

more than high school education p: 0.000 IC 95% 0.25

(0.13 - 0.46) were protectors factors of WD in this model

(Table 3).

Table 1. Sample characteristics of subjects (n = 311).

Women n (%) 271 (87)

Age, mean (range) 54 (25 - 77)

Disease duration, median (IQR) 8 (4 - 15)

Health insurance n (%) 236 (75.8)

< High school education n (%) 214 (68.8)

Paid work n (%) 85 (27.3)

Retired n (%) 48 (15.3)

Housework n (%) 39 (12.5)

Students n (%) 2 (0.6)

Unemployed due to RA n (%) 111 (35.7)

Disabled pension n (%) 26 (8.5)

Rheumatoid factor + n (%) 285 (91.6)

Function classes 3 and 4 n (%) 199 (64.2)

Radiographic erosions n (%) 234 (76)

HAQ > 1 n (%) 256 (82.3)

DAS28 > 3.2 n (%) 259 (83.3)

Disability Work among Argentinean Patients with Rheumatoid Arthritis

Table 2. Comparative analysis among patients with and without paid work (n = 223).

WD n: 137 No WD n: 86 p OR 95% CI

Women % 90% (124/137) 74% (64/86) 0.001 3.2 1.5 - 6.93

Disease duration > 5 years 65.6% (90/137) 48.8% (42/86) 0.013 2 1.1 - 3.6

Health insurance 56.9% (78/137) 75.5% (65/86) 0.005 0.4 0.2 - 0.8

RF + % 92.7% (127/137) 95% (82/86) 0.42 0.61 0.1 - 2.2

High school 22.6% (31/137) 54.6% (47/86) 0.000 0.24 0.1 - 0.4

Radigraphic erosions 77% (106/137) 68.6% (59/86) 0.146 1.5 0.8 - 2.9

Function classes 3 - 4 71.5% (98/137) 56.9% (49/86) 0.026 1.89 1 - 3.4

HAQ > 1 79.5% (109/137) 65% (56/86) 0.017 2.08 1 - 4

DAS28 > 3.2 86.8% (119/137) 80% (69/86) 0.185 1.6 0.7 - 3.5

Table 3. Multivariable logistic regression model. Patients

with and without paid work (n = 223).

Variable OR 95% CI p

Women % 3.2 (1.46 - 7.01) 0.004

Disease duration > 5 years 1.78 (0.93 - 3.4) 0.08

Health insurance 0.42 (0.21 - 0.81) 0.01

High school 0.25 (0.13 - 0.46) 0.000

HAQ > 1 1.81 (0.88 - 3.71) 0.1

Function classes 3 - 4 1.3 (0.64 - 2.68) 0.45

5. Discussion

The loss of productivity associated with RA disability

places significant burden on patients, their families and

society as a whole [7].

Work disability is defined in this article as work cessa-

tion due to RA, retirement prior to the normal age, or

disability pension due to RA.

Rates of WD reported from USA and European coun-

tries range from 22% to 85% [6]. Recently Allaire et al.

reported that 35.1% of RA patients in US were work dis-

abled [8].

In this sample of RA Argentinean patients had the

prevalence of WD was 44.05%, higher than the last re-

ports from other countries. Employment status was de-

fined for us like Allaire’s study [8].

We found high prevalence of female gender, mean age

of 54 years old, mean disease duration of 8 years, and

high scores in DAS28 and HAQ.

Education level previous of RA diagnosis was low,

and lower than others population.

Factors associated with WD in this group were female

gender, absence of medical care, more than 5 years of

disease duration, low education level, worse functional

class and high HAQ score (Table 2).

Several studies agreed that medical care and education

status are important socioeconomics predictors of work

loss. In the same form, functional class and HAQ are

predictors related to the disease [9-11].

We didn’t find association between radiographic da-

mage and disability in this group. Recent studies have

demonstrated weak relationships between damage and

disability in the first 10 years of disease course. It ap-

pears that inflammation contributes much more to the

level of disability during the first years of disease course,

whereas radiographic progression contributes more stron-

gly after about 10 years of disease duration [12]. In our

study patients had 8 years of disease duration approxi-

mately and high score of DAS28.

In the multivariable analysis were significant and in-

dependent predictors of WD female gender, absence of

medical plan and education below high school.

Female gender has been reported to be an independent

risk factor for WD in RA in several studies. RA more

frequently starts early in females indicating that females

are exposed to the inflammation longer than males [13].

M. Wallenius et al. [14] found fourfold increased risk

in females, and reported differences in pain perceptions

and worse mental health among genders could contribute

to this point.

Health insurance absence in our country is associated

Disability Work among Argentinean Patients with Rheumatoid Arthritis

to difficulties in access to the medical system, delay to

start specific treatment and less possibilities to obtain the

new available drugs. It results in worse disease evolution

and disability increase.

Fewer years of schooling often result in a physically

demanding occupation with fewer possibilities for voca-

tional rehabilitation [15].

The HAQ disability has been a correlate of permanent

work disability in almost all studies [16-18]. In this sam-

ple HAQ wasn’t a significant independent predictor of

WD. However, this is a cross section study and HAQ

score was measured at the moment of processing disabil-

ity certificate, and not in the moment that the patient de-

veloped work loss.

There are several limitations in our study. Patients who

ask for disability certificate have probably more severs

forms of the disease, and in this point our results can be

overestimated. Sample size of 311 patients does not

allow extrapolating the results to all patients with Rheu-

matoid Arthritis in our country. In this study was not

recorded the type of patient’s work. Due to the study

design, we can not establish a temporal relationship be-

tween disability and work loss.

In conclusion, our data suggest that work disability

among persons with RA in Argentina is still a substantial

problem. We need design prospective cohort studies to

estimate the prevalence of WD in this country and iden-

tify the real impact of RA on paid work.

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ResearchGate has not been able to resolve any citations for this publication.

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Article

Jan 2001

To establish the prevalence of work disability and predictors of change in employment status in patients with early rheumatoid arthritis (RA). The Norfolk Arthritis Register (NOAR), a primary-care based inception cohort of patients with recent-onset inflammatory arthritis. Two cohorts of patients notified to NOAR, who satisfied the 1987 ACR criteria for RA at the time of notification (baseline) and who were economically active at the time of RA symptom onset, were identified. Cohort 1 consisted of 160 patients with an onset of RA between 1989 and 1992, and was followed for a mean of 8.6 yr from symptom onset. For 110 of these cases, a control group, matched for age, gender and employment status at baseline, was identified from the local population. Their employment histories were compared in 1995. Cohort 2 consisted of 134 patients with an onset of RA between 1994 and 1997, and was followed for a mean of 4.1 yr from symptom onset. One-third of RA cohort 1 had stopped working on the grounds of ill health by 1995. The baseline health assessment questionnaire (HAQ) score was the most important predictor of work disability. These patients were 32 times more likely to stop work on health grounds than the matched controls. The rates for work disability for the RA cases 1, 2, 5 and 10 yr after symptom onset were 14, 26, 33 and 39% respectively. For cohort 2, the rates for work disability 1 and 2 yr from onset were 23 and 33% respectively. Work disability is an important outcome in RA patients of working age. Many people stop working very early in the disease process, often before they are referred to hospital or started on disease-modifying anti-rheumatic drugs. Although the peak rates for work disability are in the early years, people with RA continue to leave the work force several years after onset. Thus, the recent move to earlier, more aggressive treatment has had no effect on the rates of work disability.

Update on Work Disability in Rheumatic Diseases

Article

Apr 2001

Saralynn H. Allaire

Two recent studies suggest the prevalence of rheumatic condition-related work disability is considerably lower than was suggested in previous studies. However, the samples in the recent studies did not include older workers and included persons who gained employment after disease onset. In other recent studies, the rate of work disability among persons employed at disease onset is still high; a fair amount of work disability occurs in the early years of disease. There is no clear evidence yet that treatment improvements have altered the rates of work disability. Because work characteristics, like level of physical demand, influence risk for work disability and are potentially amenable, other interventions are needed to reduce rheumatic disease-associated work disability. Accommodation provided to alleviate problems in doing work and outside of work activities is the most promising intervention, followed by job/career change. Assessment tools are just now becoming available to help clinicians identify patients in need of assistance.

Epidemiology of disability in rheumatoid arthritis

Article

Mar 2002

T K Kvien

Rheumatoid Arthritis in the Developing World

Article

Nov 2003
BEST PRACT RES CL RH

The general impression is that rheumatoid arthritis (RA) has a lower prevalence and a milder course in developing countries. Epidemiological studies from different regions show that varying prevalence is possibly related to urbanization. The data suggest that where severe disability does occur, it presents a significant health challenge because of scarce medical and social resources. Disease-modifying anti-rheumatic drugs (DMARDs) remain the mainstay of therapy to alter the natural history of the disease. New therapies are unlikely to be of general benefit in the developing world because of financial constraints and increased risk of infections, particularly tuberculosis, associated with the use of tumour necrosis factor-alpha blockers. Instead, future research in poorer communities should be directed at assessing the burden of disease, the role of early aggressive therapy with DMARDs in combination with glucocorticoids for the majority of patients with RA, and finally, sourcing targeted biological therapies through clinical trials and grants for compassionate use in patients with refractory disease.

Rheumatoid arthritis: Direct and indirect costs

Article

Dec 2004
JOINT BONE SPINE

Rheumatoid arthritis (RA) causes disability, deformities, progressive radiological joint damage often with a need for joint replacement surgery, premature death, and alterations in quality of life. The economic burden created by RA is enormous. Direct costs per patient have been estimated at 1812-11,792 Euro annually and indirect costs at 1260-37,994 Euro annually. These mean values are approximations, as variations occur across countries, healthcare system organizations, and geographic locations. Direct costs account for one-fourth to slightly over a half of the total cost. Costs associated with inpatient care contribute up to 75% of direct costs, as compared to only about 20% for medications, although wide variations occur in costs related to drug monitoring and side-effect management. Physician visits account for about 20% of direct costs. As compared to indirect health costs for individuals from the general population, those for RA patients are increasing at a rapid rate. Indirect costs account for 80% of the excess cost related to RA. Cost estimates may change over time and show huge variations across individuals, with a small minority of patients accounting for most of the costs. Disability as measured by the Health Assessment Questionnaire (HAQ) has a major impact on costs. Early effective treatment may not only postpone and slow disease progression, thereby improving quality of life, but also decrease costs by preserving productivity and reducing the need for surgery, admission to acute-care and extended-care hospitals, and social service utilization. Data are beginning to accumulate on the excess costs associated with biotherapies and other new second-line drugs. They indicate acceptable excess costs relative to the additional medical benefits and to the cost-effectiveness of other healthcare programs. Nevertheless, the threshold that defines an acceptable excess cost is arbitrary and varies with local economic conditions.