Productivity at Work and Quality of Life in Patients With Rheumatoid Arthritis

Myrthe van Vilsteren; Cecile RL Boot; Dirk L Knol; Dirkjan van Schaardenburg; Alexandre E Voskuyl; Romy Steenbeek; Johannes R Anema


BMC Musculoskelet Disord. 2015;16(107) 

In This Article


In this study, we showed that workers with RA lose 4.0 hours of productive work per two weeks on average due to at-work productivity loss based on an average work week of 28.7 hours. At-work productivity loss for workers with RA is associated with both internal and external factors. Workers with worse mental health and more physical role limitations reported more lost hours at work due to presenteeism, as did workers who had ever been treated with a biological therapeutic, who were not satisfied with their work, and those with more work instability. We also showed that at-work productivity loss is negatively associated with health-related quality of life, especially in the dimensions of mental health, physical role limitations, and pain. This means that a lower quality of life on these subdomains is associated with more lost hours due to presenteeism.

Comparison With Other Studies

Only a few studies have reported on factors associated with at-work productivity loss for workers with RA. In a study by Geuskens et al. on workers with early inflammatory joint conditions, it was shown that at-work productivity loss was predicted by low support from colleagues, intermediate levels of pain, poor physical functioning and poor mental health.[11] Gignac et al. studied job disruptions (operationalized as limitations to meet work demands) in workers with inflammatory arthritis or osteoarthritis.[12] Job disruptions were associated with male sex, previous absenteeism, job change, and arthritis-work spill over (the extent to which the demands of arthritis interfered with work and work interfered with managing arthritis). In line with these studies, we found both internal and external factors related with at-work productivity. Our results show that at-work productivity loss was not only associated with physical functioning, but also with mental health, as was also found by Geuskens et al.[11]

Only one clinical factor was retained in our final model in this study (use of biological therapeutics). We found that patients who had used a biological therapeutic since their disease was diagnosed experienced more at-work productivity loss. Although a recent review showed that the use of biological therapeutics had a potentially beneficial effect on work participation.[33] Longitudinal studies included in this review generally concerned patients with high disease activity or DMARD failure. In our study, we did not select patients based on indicators of disease activity. Our findings suggest that the use of biological therapeutics may not only be considered as more effective medication for patients with higher disease activity,[34–36] but also as a marker of more severe disease. According to this criterion, patients in the present study probably have a higher than average disease severity, since the use of biologicals ever was 47.3%, whereas the total population with RA at Reade has a present biological use of 25% (according to internal communication with rheumatologists of the participating centres).

Two external factors were associated with at-work productivity loss: work instability and low job satisfaction. Work instability indicates a mismatch between functional ability and job demands.[28] In addition to the association of more work instability with more at-work productivity loss in our study, work instability was also shown to predict work transitions for patients with RA in another study.[37] Work transitions include reductions in work hours, sickness absence, job changes, and temporary employment. These findings, as well as our study results, show the potential prognostic value of the variable work instability on work-related outcomes. The importance of job satisfaction for work participation has been documented. In a study on chronic low back pain, moderate or poor job satisfaction predicted longer work absences.[38]

We found that at-work productivity loss was associated with low quality of life. This association was most profound on the mental health dimension, indicating that worse mental health is associated with more at-work productivity loss, which is in line with previous research.[11] An earlier study on patients with psoriatic arthritis showed that work-disabled patients experience worse mental health compared to working patients.[14] This finding indicates that actually having a paid job has a positive influence on mental health. In our study of working patients with RA, we found that the mean scale score on the mental health scale of the RAND 36 was comparable to the Dutch normal value for this subscale.[22] Although our population on average did not have impaired on mental health, mental health remains a topic of concern, since for our patients with RA, worse mental health was associated with more at-work productivity loss.

We validated our multivariate model in our population (internal validation).[39] In previous studies, multivariate models have been mainly used for dichotomous outcomes (i.e. sick/not sick). For dichotomous multivariate models, two studies performed an internal validation of their model.[40,41] They compared, amongst others, R2 values that were comparable (<10% change in R2) between the multivariate model and validation model.[40,41] For prediction models with continuous outcomes, there are no validation studies available to our knowledge. Our R2 in the main sample was 0.50, and 0.32 in our validation sample. This decline indicates that the factors best associated with at-work productivity loss should be interpreted cautiously.

Strengths and Limitations

A strength of our study was that we included a variety of both internal and external factors in our analyses, instead of focusing on clinical factors only, for example. The average number of work hours lost due to presenteeism is in line with previous research. In a study by Zhang et al. who also measured at-work productivity loss with the WLQ, 4.0 hours were lost every two weeks due to presenteeism, although the average number of work hours was 35 hours per week in their study, compared to 28.7 hours in our study.[42] This supports the representativeness of our study sample.

A limitation is that our results are based on cross sectional data, therefore, we cannot distinguish causes and consequences.

Our results concern workers with RA who experienced at least minor difficulties at work. We were therefore not able to study the incidence of presenteeism.

We assessed sick leave with a long recall period, which can introduce recall bias. From previous research however, it seems that self-reports of sick leave are accurate when compared to sick leave registries.[43]

Study Implications

Further research should focus on work functioning, and predictors for at-work productivity loss in cohort (longitudinal) studies to identify those patients most at risk.

Our results give an indication of risk factors for at-work productivity loss, but further investigation is needed for more robust findings. Since patients experiencing at-work productivity loss are at risk for sick leave and permanent work disability, it is important to know which factors contribute to at-work productivity loss, in order to develop interventions to improve at-work productivity loss and thereby prevent work disability. We included a broad range of potential factors, such as personal factors, clinical characteristics, and work-related factors in our analysis. Our multivariate model shows that the factors best associated with at-work productivity loss are drawn from all three domains. Future research should consider the potential impact of both personal and work-related factors in addition to clinical characteristics.

The importance of personal and work-related factors should also be acknowledged in current clinical practice if the goal is to enhance work participation. This means that treating physicians should not only focus on improving disease severity when treating patients with RA who are struggling to maintain work productivity, but they should also pay attention to personal- and work-related factors for a more holistic approach.