Publicação
The impact of rheumatic diseases on early retirement
| Resumo: | BACKGROUND: Rheumatic Diseases (RD) are characterized by pain and reduction in the range of motion and function in one or more areas of the musculoskeletal system. RD are prominent causes of morbidity and disability throughout the world, giving rise to enormous healthcare expenditures. RD may also lead to early retirement, generating indirect costs to society, namely through its most prevalent nosologic entity, osteoarthritis (OA). OBJECTIVES: This study primarily aimed: 1) To examine the association between RD and early retirement in the Portuguese population; 2) To measure the productivity loss associated with early retirement attributable to RD in Portugal; and 3) To review possible effective interventions targeting early retirement due to RD. METHODS: In order to achieve these objectives individual level data from two national, cross-sectional, population-based surveys were used - the National Health Survey, conducted in 2005-2006 (INS) and the first nationwide study on RD, conducted in 2011-2013 (EpiReumaPt). Both surveys had samples considered to be representative of the regions of mainland Portugal (North, Center, Lisbon region, Alentejo, and Algarve) and the autonomous regions of the Azores and Madeira. All participants aged between 50 and 64 years old, approaching the statutory pension age, were included in the analysis (INS: 3762 men and 4241 women; EpiReumaPt: 1065 men and 1727 women). The presence of RD was based on self-report by the surveys’ participants. Due to its prevalence and associated disability a special interest was devoted to OA, which was defined by the clinically diagnosis of OA initially done by a rheumatologist in a patient interview and further validated by other 3 experienced rheumatologists in the EpiReumaPt study, according with the American College of Rheumatology (ACR) classification criteria. Regarding the main dependent variable, a lato and stricto sensu definition of premature job loss was adopted, which enabled taking into consideration the existence of different pathways to early retirement. In addition, anticipated retirement due to RD directly reported by the EpiReumaPt participants was analysed. Other variables of interest, in particular those potentially influencing early retirement, were described and analysed as well. These included sociodemographic, ill-health, lifestyle, and socioeconomic factors. The effects of self-reported RD and OA on the likelihood of early retirement were obtained at the individual level by logistic regression, using a manual stepwise technique (backward elimination). The population attributable fractions (PAF) were also calculated as the resulting proportional change in the probability of retirement after a counterfactual exercise where the presence of a RD was artificially eliminated from the sample. In order to calculate indirect costs following early retirement attributable or due to RD, an official national public source (Quadros do Pessoal / Personnel Records from the Ministry of Solidarity and Social Security) was used to estimate unit values of production by gender, age-group and region, using the human capital approach, which values healthy time lost due to RD using market wage rates (adjusted for social security contributions). Years of working life lost (YWLL) were estimated as the difference between each participant’s current age and the respective retirement age, while the potential years of working life lost (PYWLL) were given by the difference between official and actual retirement ages. The share of time in inactivity was also calculated (Inactivity ratio=YWLL/active age-range). All results were computed as weighted data, in order to take into account the stratified sampling design of the surveys. Statistical analyses were carried out using Stata 12.0. Finally, a comprehensive review using PubMed, the Cochrane Library and the Portuguese institutional repositories was done to identify and analyse studies either in English or Portuguese published between January 2000 and June 2016 that evaluated the impact of interventions targeting early retirement in RD patients. RESULTS: In 2005-2006 (INS), 37.2% of the Portuguese population aged 50-64 years self-reported at least one RD and among these 52.6% were not employed, compared with 40.7% of those without RD (p<0.001). 45.1% of the studied population was not employed and more frequently self-reported “poor” to “very poor” health than those employed (31.6% vs. 16.4%, respectively; p<0.001). A larger average number of major chronic diseases per capita was also found in those not employed (1.9 vs. 1.4, p<0.001). RD were more prevalent (43.4% vs. 32.1%; p<0.001) and independently associated with early retirement (OR: 1.24; CI: 1.01- 1.52) and broad early exit from work (OR: 1.31; CI: 1.12-1.52). The annual indirect costs following premature exit from work attributable to RD were €650 million (€892 per RD patient), while early retirement amounted to €367 million (€504 per RD patient).In 2011-2013 (EpiReumaPt), 34.2% of the studied population self-reported at least one RD and among these 58% were not employed. 51.6% of the studied population was not employed and 29.9% were retired. Among the early retirees, 43.2% were on grounds of ill-health (12.9% of the overall sample), of which in turn about a third (30.4%) was specifically due to RD. Thus, 13.1% of all retirees and 3.9% of the Portuguese population within the studied age-range self-reported RD as the main reason for early retirement. Those who were employed (48%) had higher levels of education, were less obese and had a lower number of chronic diseases compared with participants out of work, in particular those early retired due to RD. Employed people also have less RD than the early retirees (30.0% vs. 40.2%, respectively; p<0.001). In fact, as in 2005-2006 with the INS database, self-reported RD was independently associated with early retirement (OR: 1.37; CI: 1.01-1.84). The majority of the early retirement due to RD was observed in females (81.6% vs. 41.5% of females in the early retirement group unrelated with RD). The estimated early retirement self-reportedly to be caused by RD is potentially associated with an annual cost of up to €910 million (€555 per capita; €1625 per self reported RD patient and €13,592 per early retiree due to RD). Females contributed with the majority of these costs (€766 million; €882 per female versus €187 per male). We observed a total number of 389,939 accumulated YWLL (228 per 1000 inhabitants) and 684,960 PYWLL (401 per 1000 inhabitants). The mean YWLL and PYWLL inactivity ratios were 12% and 21%, respectively. Participants with higher values of disability, measured by the Health Assessment Questionnaire (HAQ), have the highest risk of early retirement (OR: 1.58; CI: 1.27-1.97). The individuals with RD and highest levels of disability (i.e. HAQ scores ≥ 2) are at the utmost risk of early retirement (55.3% vs. 35.1% for all RD population and 31.9% for those with HAQ scores ≥ 2 but without RD). An almost linear relationship between levels of disability and the probability of early retirement was observed, with its y-intercept and slope being increased by RD, which is consistent with the results obtained with OA. Still using the EpiReumaPt survey, it was estimated a prevalence of clinically confirmed OA in the studied age-group of 29.7% (men: 16.2% and women: 43.5%. Knee OA: 18.6%; hand: 12.6%; hip: 3.6%). OA was associated with early exit from paid employment, specifically knee OA (OR: 2.25; CI: 1.42-3.59), but not with early retirement stricto sensu, since unemployment seems to be a major channel of work loss for patients with OA. Other OA locations did not have a statistically significant effect on work loss. Early exit from paid employment due to OA led to a total of 143,262 YWLL and 338,822 PYWLL (84 and 198 per 1000 inhabitants in the studied age-group, respectively). The estimated annual indirect cost attributable to OA was €656 million (€384 per capita; €1294 per OA patient and €2095 per OA patient out of work). Knee OA patients with worst scores on symptoms, pain, quality of life and ability to perform activities of daily living, measured by the Knee injury and Osteoarthritis Outcome Score (KOOS), were more likely to be found out of work. This particularly applies for pain, which seems to play a key role in the risk of workforce withdrawal. A strong association was seen between pain interference and premature work loss, especially within the knee OA population (OR: 1.52; CI: 1.16-1.99). Concerning the literature revision on possible interventions aiming to reduce early retirement, several published studies testing pharmacologic and non-pharmacologic vocational rehabilitation interventions were identified. None was specifically identified for Portugal. The general low quality of the literature and its inconsistency makes it unfeasible to draw definitive conclusions. However, some broad recommendations were outlined. Despite the lack of good quality evidence on this field, there seems to be a growing interest in the international scientific community with several ongoing promising studies promoting such interventions. CONCLUSIONS: In Portugal, self-reported RD are associated with early exit from paid work, specifically early retirement. Currently, there is a meaningful number of people who claimed to be retired prematurely due to RD. This translates in many years of working life already lost and many others still potentially to be lost. Indirect costs due to self-reported RD are also substantial, equivalent to at least 0.5% of the Portuguese GDP. By specifically analysing OA, the most prevalent rheumatic disorder, it was possible to verify that the productivity loss due to RD is potentially even higher than the one obtained when analysing self-reported RD as a whole. Regardless the exact magnitude of the estimates, it seems undisputable that the foregone productivity caused by RD is enormous. Due to the lack of good quality data and the inconsistency currently found in the literature, it is difficult to recommend an intervention expected to be inevitably effective. Given the lack of longitudinal assessments, it is utterly important to promote further research based on long-term cohorts aiming to collect occupational and health information in our country, as well as data on the impact of interventions targeting early retirement caused by rheumatic disorders. |
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| Autores principais: | Laires, Pedro Almeida, 1979- |
| Assunto: | Doenças reumáticas Aposentação Epidemiologia Osteoartrite Teses de doutoramento - 2017 |
| Ano: | 2017 |
| País: | Portugal |
| Tipo de documento: | tese de doutoramento |
| Tipo de acesso: | acesso aberto |
| Instituição associada: | Universidade de Lisboa |
| Idioma: | inglês |
| Origem: | Repositório da Universidade de Lisboa |
| Resumo: | BACKGROUND: Rheumatic Diseases (RD) are characterized by pain and reduction in the range of motion and function in one or more areas of the musculoskeletal system. RD are prominent causes of morbidity and disability throughout the world, giving rise to enormous healthcare expenditures. RD may also lead to early retirement, generating indirect costs to society, namely through its most prevalent nosologic entity, osteoarthritis (OA). OBJECTIVES: This study primarily aimed: 1) To examine the association between RD and early retirement in the Portuguese population; 2) To measure the productivity loss associated with early retirement attributable to RD in Portugal; and 3) To review possible effective interventions targeting early retirement due to RD. METHODS: In order to achieve these objectives individual level data from two national, cross-sectional, population-based surveys were used - the National Health Survey, conducted in 2005-2006 (INS) and the first nationwide study on RD, conducted in 2011-2013 (EpiReumaPt). Both surveys had samples considered to be representative of the regions of mainland Portugal (North, Center, Lisbon region, Alentejo, and Algarve) and the autonomous regions of the Azores and Madeira. All participants aged between 50 and 64 years old, approaching the statutory pension age, were included in the analysis (INS: 3762 men and 4241 women; EpiReumaPt: 1065 men and 1727 women). The presence of RD was based on self-report by the surveys’ participants. Due to its prevalence and associated disability a special interest was devoted to OA, which was defined by the clinically diagnosis of OA initially done by a rheumatologist in a patient interview and further validated by other 3 experienced rheumatologists in the EpiReumaPt study, according with the American College of Rheumatology (ACR) classification criteria. Regarding the main dependent variable, a lato and stricto sensu definition of premature job loss was adopted, which enabled taking into consideration the existence of different pathways to early retirement. In addition, anticipated retirement due to RD directly reported by the EpiReumaPt participants was analysed. Other variables of interest, in particular those potentially influencing early retirement, were described and analysed as well. These included sociodemographic, ill-health, lifestyle, and socioeconomic factors. The effects of self-reported RD and OA on the likelihood of early retirement were obtained at the individual level by logistic regression, using a manual stepwise technique (backward elimination). The population attributable fractions (PAF) were also calculated as the resulting proportional change in the probability of retirement after a counterfactual exercise where the presence of a RD was artificially eliminated from the sample. In order to calculate indirect costs following early retirement attributable or due to RD, an official national public source (Quadros do Pessoal / Personnel Records from the Ministry of Solidarity and Social Security) was used to estimate unit values of production by gender, age-group and region, using the human capital approach, which values healthy time lost due to RD using market wage rates (adjusted for social security contributions). Years of working life lost (YWLL) were estimated as the difference between each participant’s current age and the respective retirement age, while the potential years of working life lost (PYWLL) were given by the difference between official and actual retirement ages. The share of time in inactivity was also calculated (Inactivity ratio=YWLL/active age-range). All results were computed as weighted data, in order to take into account the stratified sampling design of the surveys. Statistical analyses were carried out using Stata 12.0. Finally, a comprehensive review using PubMed, the Cochrane Library and the Portuguese institutional repositories was done to identify and analyse studies either in English or Portuguese published between January 2000 and June 2016 that evaluated the impact of interventions targeting early retirement in RD patients. RESULTS: In 2005-2006 (INS), 37.2% of the Portuguese population aged 50-64 years self-reported at least one RD and among these 52.6% were not employed, compared with 40.7% of those without RD (p<0.001). 45.1% of the studied population was not employed and more frequently self-reported “poor” to “very poor” health than those employed (31.6% vs. 16.4%, respectively; p<0.001). A larger average number of major chronic diseases per capita was also found in those not employed (1.9 vs. 1.4, p<0.001). RD were more prevalent (43.4% vs. 32.1%; p<0.001) and independently associated with early retirement (OR: 1.24; CI: 1.01- 1.52) and broad early exit from work (OR: 1.31; CI: 1.12-1.52). The annual indirect costs following premature exit from work attributable to RD were €650 million (€892 per RD patient), while early retirement amounted to €367 million (€504 per RD patient).In 2011-2013 (EpiReumaPt), 34.2% of the studied population self-reported at least one RD and among these 58% were not employed. 51.6% of the studied population was not employed and 29.9% were retired. Among the early retirees, 43.2% were on grounds of ill-health (12.9% of the overall sample), of which in turn about a third (30.4%) was specifically due to RD. Thus, 13.1% of all retirees and 3.9% of the Portuguese population within the studied age-range self-reported RD as the main reason for early retirement. Those who were employed (48%) had higher levels of education, were less obese and had a lower number of chronic diseases compared with participants out of work, in particular those early retired due to RD. Employed people also have less RD than the early retirees (30.0% vs. 40.2%, respectively; p<0.001). In fact, as in 2005-2006 with the INS database, self-reported RD was independently associated with early retirement (OR: 1.37; CI: 1.01-1.84). The majority of the early retirement due to RD was observed in females (81.6% vs. 41.5% of females in the early retirement group unrelated with RD). The estimated early retirement self-reportedly to be caused by RD is potentially associated with an annual cost of up to €910 million (€555 per capita; €1625 per self reported RD patient and €13,592 per early retiree due to RD). Females contributed with the majority of these costs (€766 million; €882 per female versus €187 per male). We observed a total number of 389,939 accumulated YWLL (228 per 1000 inhabitants) and 684,960 PYWLL (401 per 1000 inhabitants). The mean YWLL and PYWLL inactivity ratios were 12% and 21%, respectively. Participants with higher values of disability, measured by the Health Assessment Questionnaire (HAQ), have the highest risk of early retirement (OR: 1.58; CI: 1.27-1.97). The individuals with RD and highest levels of disability (i.e. HAQ scores ≥ 2) are at the utmost risk of early retirement (55.3% vs. 35.1% for all RD population and 31.9% for those with HAQ scores ≥ 2 but without RD). An almost linear relationship between levels of disability and the probability of early retirement was observed, with its y-intercept and slope being increased by RD, which is consistent with the results obtained with OA. Still using the EpiReumaPt survey, it was estimated a prevalence of clinically confirmed OA in the studied age-group of 29.7% (men: 16.2% and women: 43.5%. Knee OA: 18.6%; hand: 12.6%; hip: 3.6%). OA was associated with early exit from paid employment, specifically knee OA (OR: 2.25; CI: 1.42-3.59), but not with early retirement stricto sensu, since unemployment seems to be a major channel of work loss for patients with OA. Other OA locations did not have a statistically significant effect on work loss. Early exit from paid employment due to OA led to a total of 143,262 YWLL and 338,822 PYWLL (84 and 198 per 1000 inhabitants in the studied age-group, respectively). The estimated annual indirect cost attributable to OA was €656 million (€384 per capita; €1294 per OA patient and €2095 per OA patient out of work). Knee OA patients with worst scores on symptoms, pain, quality of life and ability to perform activities of daily living, measured by the Knee injury and Osteoarthritis Outcome Score (KOOS), were more likely to be found out of work. This particularly applies for pain, which seems to play a key role in the risk of workforce withdrawal. A strong association was seen between pain interference and premature work loss, especially within the knee OA population (OR: 1.52; CI: 1.16-1.99). Concerning the literature revision on possible interventions aiming to reduce early retirement, several published studies testing pharmacologic and non-pharmacologic vocational rehabilitation interventions were identified. None was specifically identified for Portugal. The general low quality of the literature and its inconsistency makes it unfeasible to draw definitive conclusions. However, some broad recommendations were outlined. Despite the lack of good quality evidence on this field, there seems to be a growing interest in the international scientific community with several ongoing promising studies promoting such interventions. CONCLUSIONS: In Portugal, self-reported RD are associated with early exit from paid work, specifically early retirement. Currently, there is a meaningful number of people who claimed to be retired prematurely due to RD. This translates in many years of working life already lost and many others still potentially to be lost. Indirect costs due to self-reported RD are also substantial, equivalent to at least 0.5% of the Portuguese GDP. By specifically analysing OA, the most prevalent rheumatic disorder, it was possible to verify that the productivity loss due to RD is potentially even higher than the one obtained when analysing self-reported RD as a whole. Regardless the exact magnitude of the estimates, it seems undisputable that the foregone productivity caused by RD is enormous. Due to the lack of good quality data and the inconsistency currently found in the literature, it is difficult to recommend an intervention expected to be inevitably effective. Given the lack of longitudinal assessments, it is utterly important to promote further research based on long-term cohorts aiming to collect occupational and health information in our country, as well as data on the impact of interventions targeting early retirement caused by rheumatic disorders. |
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