Disability Work among Argentinean Patients with Rheumatoid Arthritis

doi:10.4236/ojra.2012.23014

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

http://dx.doi.org/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: [email protected]

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

ABSTRACT

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

National Rehabilitation Service (NRS); 2) To measure general, socioeconomics and disease ch aracteristics 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). Th e prevalence of WD wa s 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 independ ent 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. Socio economics 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 cond ition 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 patien t and less productivity for so ci-

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 constru cted 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 rheu matoid 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, subj ects 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% (124/13 7) 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 defin ed in this article as work cessa-

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

disability pension du e 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 rehabilitatio n [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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