Objective. Job loss is a major consequence of rheumatic diseases, and clinicians may refer patients to vocational rehabilitation for help. When provided after job loss, the impact of vocational rehabilitation is short term. This randomized controlled trial with 48 months of followup was undertaken to determine the efficacy of vocational rehabilitation provided to persons with rheumatic diseases while they are still employed, but at risk for job loss.Methods. A total of 242 patients with rheumatic diseases residing in Massachusetts were recruited through their rheumatologists for study. Participants were randomly assigned to the experimental group (n ‫؍‬ 122) or the control group (n ‫؍‬ 120). Subjects in the experimental group received two 1.5-hour sessions of vocational rehabilitation; those in the control group received print materials about disability employment issues and resources by mail. The main outcome assessed was the time to first job loss. Job losses were defined as permanent disability, premature retirement, or a period of unemployment. All analyses were conducted on an intent-to-treat basis.Results. Job loss was delayed in the experimental group compared with the control group (P ‫؍‬ 0.03 by log rank test). After adjustment for confounders, participation in the experimental group was found to be protective against job loss (odds ratio 0.58 [95% confidence interval 0.34-0.99], P ‫؍‬ 0.05 by pooled logistic regression).Conclusion. Vocational rehabilitation delivered to patients at risk for job loss, but while they were still employed, delayed job loss. Such an intervention has the potential to reduce the high indirect costs, as well as the personal impact, of rheumatic diseases.Health-related job loss is a major consequence of rheumatic diseases. In the most recent analyses (1), costs stemming from lost wages, so-called indirect costs, for all forms of arthritis were 74% of the total costs, while the direct costs of medical care were 26% of the total. This burden can be expected to increase because the portion of the US work force that is 55 years of age and older is increasing (by 2020, it will account for one-fifth of the work force) (2) and because the incidence and prevalence of many rheumatic diseases rise substantially after age 50 years. Health-related job loss also exacts a substantial toll on the quality of life of individuals, being associated with lower levels of self-esteem, life satisfaction, adaptation, perceived health status, and in those with rheumatoid arthritis, higher levels of depression and pain (3-5).Vocational rehabilitation is one approach to addressing health-related job loss. Rheumatologists and other clinicians may wish to refer their patients with rheumatic diseases to vocational rehabilitation for help. However, there is a shortage of studies evaluating the effectiveness of vocational rehabilitation. Studies that have been done suggest that while it can be effective in helping persons with disabilities regain employment, this effect is often short-lived (6). Moreover, the...

Objective. To study additional risk factors for rheumatoid arthritis @A)-related work disability and to identify the groups of individuals at high risk and thepotentially modifiable factors which place them at risk. Methods. A cross-sectional mail survey was conducted among 469 adults with RA. Work disability was defined as unemployment due to RA. A broad range of explanatory factors was examined, including sociodemographic, health, work, support given by others, and commuting difficulty. Employed and workdisabled subjects were compared by t-test and chisquare. Attributable fractions were calculated to assess the predictive value of factors. A recursive partitioning procedure identified individuals at vay'ng risks for work disability, and their characteristics were defined. Results. The risk factors joint pain and functional status, commuting difficulty, physical demands of the job, and disease duration were important predictors of work disability in both the attributable fraction and recursive partitioning analytic models. Having a professional or administrative job was protective, provided the salary earned was not low. Younger individuals with RA of shorter duration were placed at high risk by potentially modifiable factors. While older persons with RA of long duration were at high risk, modifiable factors could not be identified. Conclusion. Commuting difficulty, a previously overlooked factor, is an important predictor of RA work disability. Younger individuals with RA of relatively short duration can be placed at high risk by potentially modifiable factors including commuting difficulty, physically demanding jobs, greater joint pain and poor functional status, and nonprofessional/nonadministrative jobs.

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.

The economic costs associated with rheumatoid arthritis (RA), a chronic, systemic, inflammatory disorder that affects many joints, are high, approximating those of coronary heart disease. The estimated prevalence of RA in the US is 0.9%. Incidence increases with age, and is highest among women in the fourth to sixth decades of life. The primary impact of RA is due to the significant morbidity associated with this disease. Mortality is increased among a poorly defined subgroup of RA patients. The average level of disability among RA patients is moderate, but 6.5 to 12% of patients are severely disabled. Between one- and two-thirds of previously employed patients have a reduced work capacity. Treatment primarily involves the use of nonsteroidal anti-inflammatory drugs and disease modifying antirheumatic drugs. Rehabilitation measures and orthopaedic surgery are also used. Total annual direct costs of RA (total charges) have been calculated to be $US5275 and $US6099 (1991 dollars) per patient. Lifetime medical care charges were estimated at $US12,578 per patient (1991 dollars). The direct costs of RA are substantial, but indirect costs have been calculated to be much higher because of extensive morbidity. The difference between the direct and indirect costs of RA is decreasing because salary increases have not kept pace with rising healthcare costs. The latter are increasing rapidly in RA because of the use of new technology, surgical procedures, and the greater use of drugs with frequent monitoring requirements and significant toxicity. Because intangible costs such as pain form a substantial part of the overall costs of RA but are difficult to evaluate, cost estimates inevitably underestimate the impact of the disease on individuals and society.

New research is urgently needed to reduce the burden of work disability on individuals and society.

Objective. To examine the extent and financial impact of work disability among older workers with rheumatoid arthritis (RA). Methods. Year 2002 data from 5,419 subjects with RA <65 years of age in the National Data Bank for Rheumatic Diseases were used, along with US population data. Measures of work disability were employment status, part-time work, sick day use, and limitation in work demands; the latter was assessed by the Work Limitations Questionnaire (WLQ). Measures of financial status were median household income and poverty level income. Statistical procedures included logistic and linear regression, Wilcoxon's rank sum test, and chi-square test. Results. Despite being better educated, subjects with RA ages 55-64 years had lower employment rates than individuals of the same age in the US (women 40% versus 53% and men 54% versus 66%). These older subjects with RA had stopped working more often than younger subjects with RA, and more worked part time (40% versus 34%; P < 0.01). However, the older subjects used sick time less often than younger subjects (35% versus 41%; P < 0.01) and were similarly limited in job demands, e.g., physical demands (mean WLQ subscale score 27.0 versus 26.6; P ‫؍‬ 0.65). Median household income of older employed subjects was $20,000 greater than that of retired subjects; 56% of retired subjects had incomes lower than US median income versus 32% of employed subjects, and 11% had income below the poverty level. Conclusion. Premature work cessation in persons with RA ages 55-64 years is a serious problem that needs to be addressed.

Objective. To provide a contemporary estimate of the prevalence and incidence of rheumatoid arthritis (RA) work disability and examine its permanence over time. Methods. Data were collected semiannually from 5,384 subjects with rheumatologist-diagnosed RA. We examined prevalence in subgroups formed by ϳ5-year disease duration intervals using data from subjects age <64 years who were employed at disease onset. Annual incidence was examined longitudinally among subjects who supplied data in 2003, 2004, or 2005, were employed at disease onset and in a year's first survey, and were age <63 years. For work disability permanence we used longitudinal data from all subjects who became work disabled and observed whether they later returned to work. Results. Mean age of subjects was 52 years, 82% were female, 63% had more than a high school education, mean disease duration was 14 years, and mean Health Assessment Questionnaire score was 1.0. The prevalence of any premature work cessation was 23% in subjects with 1-3 years duration, 35% in those with 10 years, and 51% in those with >25 years RA duration. Arthritis-attributed work cessation was 14%, 29%, and 42%, respectively. Annual incidence of any premature work cessation was ϳ10% and arthritis-attributed work cessation incidence was ϳ6%. Thirty-nine percent of subjects who stopped working later returned to work. Conclusion. Work disability prevalence in this sample was high (35% within 10 years disease duration), but may represent a decline from the 50% prevalence reported in 1987. Annual incidence of work disability was higher than prior studies, but the return to work rate was also higher.

Many people with arthritis become work disabled, but little is known about (a) the types of work barriers they experience and (b) their use of job accommodations. Our objectives were to describe work barriers and use of accommodations and to examine factors associated with accommodation use in persons with arthritis at risk for work disability. Barrier assessment was conducted using the Work Experience Survey. Factors associated with accommodation use were analyzed by logistic regression. The overwhelming majority of the 121 participants (98%) reported having one or more barriers, and 68% reported 10 or more barriers; 38% used an accommodation. Greater functional limitations and self-efficacy for accommodation request were each associated with accommodation use. Even though these employed persons with arthritis faced multiple barriers at work, only a small number used any form of job accommodation.