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European Journal of Heart Failure 2007 9(11):1112-1119; doi:10.1016/j.ejheart.2007.08.002
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© 2007 European Society of Cardiology

Return to work after thoracic organ transplantation in a clinically-stable population

Lucia Petruccia, Susanna Ricottia, Ilaria Michelinib, Patrizio Vituloc, Tiberio Oggionnic, Alessandro Cascinac, Andrea M. D'Arminid, Claudio Goggid, Carlo Campanae, Mario Viganòd, Elena Dalla-Toffolaa, Carmine Tinellib and Catherine Klersyb,*

a Physical Medicine and Rehabilitation, Fondazione IRCCS Policlinico San Matteo, University of Pavia Pavia, Italy
b Service of Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico San Matteo 27100, Pavia, Italy
c Respiratory Disease Unit, Fondazione IRCCS Policlinico San Matteo, University of Pavia Pavia, Italy
d Division of Cardiac Surgery, Fondazione IRCCS Policlinico San Matteo, University of Pavia Pavia, Italy
e Department of Cardiology, Fondazione IRCCS Policlinico San Matteo Pavia, Italy

* Corresponding author. Tel.: +39 0382 503557; fax: +39 0382 502075. E-mail address: klersy{at}smatteo.pv.it


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Statistical analysis
 4. Results
 5. Discussion
 6. Conclusion
 References
 
Purpose: To evaluate the rate of return to work after transplantation and its determinants in a clinically-stable population of patients transplanted and followed-up at a single institution in Italy.

Methods: 151 thoracic organ transplant recipients (72 lung, 79 heart) were examined. Patients were asked about daily activities, level of education, employment and clinical condition. A six-minute walking test was performed with measurement of dyspnoea using the Borg scale. Quality of Life was evaluated with the SF-36 and GHQ questionnaires.

Results: Before transplantation 131 patients (87%), (70 heart and 61 lung) worked. After transplantation, 51 patients (39%) went back to work and 3 more started working. We found that younger age, a better quality of life (mainly in the mental domain), having had an occupation previously (particularly as an entrepreneur/freelancer), and having been off work for less than 24months, were independent predictors of return to work.

Conclusions: Considering their good, objective and subjective, functional status, some patients who could have returned to work, chose not to. Identifying factors which affect return to work might help health professionals to adopt the best course of treatment and psychological support in order to fulfil this goal; however, return to work should not be considered as the only expression of a patient's real psychophysical condition.

Key Words: Thoracic organ transplantation • Employment • Return to work • Quality of life

Received May 16, 2007; Accepted August 15, 2007


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Statistical analysis
 4. Results
 5. Discussion
 6. Conclusion
 References
 
The increase in the number of "long-term survivors" after thoracic organ (heart-lung) transplantation, combined with the rapid disappearance of pre-transplant symptoms and the definite improvement in quality of life, means that return to work is now considered as a further indicator of post-transplantation outcome. However, return to work after transplantation is not widely covered in the literature, and there is no specific data for Italy, where the transplant program started in 1985.

Return to work after transplantation is an important goal after thoracic organ transplant, not only for financial reasons but also for the patient's sense of personal achievement, and as such, it is reportedly associated with a better quality of life [1-4]. Return to work is considered an important element when evaluating the social domain after transplant [5]. Two recent reviews of reports mainly published in the 1990s [5,6], report rates of return to work of between 20 to 80%. Several factors can affect a patient's decision to return to work after organ transplantation; including age, years of full-time education, his/her own perception of being physically or emotionally able to resume work, type of health insurance or the payment of a disability allowance, length of time since transplantation and the length of time off work prior to transplant [5,7-11]. Compared to other countries, transplant patients in Italy receive good institutional social support, which could influence their attitude towards returning to work.

The goal of our study was to evaluate the rate of return to work after transplantation and its determinants in a population of clinically-stable patients transplanted and followed-up at a single institution in Italy, who attended the outpatient clinic at the time of the study.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Statistical analysis
 4. Results
 5. Discussion
 6. Conclusion
 References
 
2.1. Patients
The transplant program at our Centre has enrolled 883 and 301 patients in the heart and lung transplant programs, respectively. For heart transplantees, the cumulative survival at 1 and 5 years is 86% and 77%, respectively. For lung transplantees (including 34 heart and lung recipients), cumulative survival at 1 and 5 years is 80% and 59% for single lung transplant, 62% and 35% for double lung transplant and 58% and 32% for heart and lung transplant. All transplant patients undergo follow-up assessments at the outpatient clinics of our hospital. In case of clinical deterioration, patients are seen for additional unplanned visits and are hospitalised if necessary.

2.2. Sampling scheme
This case series includes a systematic sample of heart and/or lung transplant recipients who attended the outpatient clinic for routine check-ups at our Institution, on two predefined days of the week, over the 6 month duration of the study. In order to identify subjects likely to be eligible to return to work, only patients who had undergone transplant surgery at least 6 months earlier and attending for routine controls were enrolled. These patients were classified as being in a clinically-stable condition. Patients who had an unscheduled visit for a deteriorating clinical condition were not considered eligible.

One hundred and fifty-one patients took part in the study. Of these, 72 patients (47 male, mean age 47 years, SD 13) had undergone lung transplantation and 79 patients (65 male, mean age 52 years, SD 15) heart transplantation. Patients were examined a median of 45 months (IQR 18-84) after transplant. The occurrence of infection or acute rejection in the previous month was recorded, as was the presence of chronic rejection (coronary heart disease/BOS) and of current infection. Information on daily activities after transplantation (going out, climbing stairs, use of car and bicycle); level of education (years of full-time education); employment status before and after transplantation (white collar workers, entrepreneurs/freelance, blue-collar workers, self-employed, unemployed, retired or students [12]); and sports practised before and after transplantation were collected during a personal interview and recorded in an ad-hoc designed database. Exercise capacity was assessed by the six-minute walking test (6MWT), using a standard protocol [13]. The Borg Scale was used to measure dyspnoea both before and after the 6MWT [14]. Two self-administered questionnaires were used to measure Quality of Life (QoL): the Medical Outcome Study 36-Item Short Form Health Survey (SF-36, Italian version) [15,16] and the General Health Questionnaire (GHQ) (Italian version) [17,18]. The SF-36 is an internationally-validated general health survey. Eight dimensions are explored: physical functioning (PF); role physical (RP), exploring role limitations due to physical problems; bodily pain (BP); general health (GH); vitality (VT); social functioning (SF); role emotional (RE), exploring role limitations due to emotional problems; and mental health (MH). The SF-36 also asks patients to rate their own health, as compared to the previous year, on a scale ranging from 1 to 5 (corresponding to: much better now, somewhat better, about the same as, somewhat worse and much worse than one year ago). The questionnaires were scored and validated according to the SF-36 manual [15]. Norm-based scores, based on the 1998 Italian population, were calculated for the 8 dimensions, in order to allow a direct comparison with a normal reference population. In addition, Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were calculated; these combine information on the mental and physical components from the 8 dimensions [16,19]. Scores of 50 are the average for the Italian Reference Population. Higher scores correspond to a better QoL. The General Health Questionnaire (GHQ-30 items) is a recognized instrument for detecting current non-psychotic disorders and has been widely used to detect potential minor psychiatric disorders. Scores can range from 0 to 30; the lower the score the better the QoL. A threshold between 5 and 6 was used in the present study to identify patients with psychological discomfort [17,18,20].

The research protocol was approved by the local Ethics Board. Informed consent was obtained from all patients before entering the study.


   3. Statistical analysis
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistical analysis
4. Results
 5. Discussion
 6. Conclusion
 References
 
Data are presented as mean and standard deviation (SD) or median and interquartile range (IQR) for continuous variables and counts and as percentages for categorical variables. Mean and 95% confidence intervals (95% CI) were computed for the SF-36 norm-based scores. These were compared to the Italian age and sex adjusted "norm" by means of the Student t test. We used the Fisher exact test and Mann Whitney U test for a univariable comparison of categorical and continuous variables between patients who did or did not return to work. For the purpose of the analysis, patients with heart and with lung transplant were combined into a single group. The McNemar exact test was used to compare the proportion of subjects working before and after transplantation. To identify independent predictors of return to work, a multivariable logistic model was fitted. Backward stepwise elimination was performed, with a p-value to remove of 0.2. Odds ratios (OR) and 95% confidence intervals were computed (95% CI). Model validation was assessed by calculating the bootstrapped c statistic and shrinkage coefficient. We included in the model a series of non collinear variables, shown to be relevant in the existing literature, unless found totally irrelevant at the univariable analysis (p > 0.2) (see Table 2). Stata 9 (StataCorp, College Station, TX) was used for computation. A two-sided p-value was considered statistically significant.


   4. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistical analysis
 4. Results
5. Discussion
 6. Conclusion
 References
 
4.1. Population characteristics
One hundred and fifty-one patients, mean age 50 years (SD 14) were included in the study (Table 1). Due to the sampling scheme, in which only patients on routine follow-ups were enrolled, our population were considered to be in a stable clinical condition. All the heart transplantees were in NYHA class I (98%) or II. Lung transplantees had a mean FEV1 of 2.5l (SD 0.93). Eleven patients (7%) had had an episode of acute rejection in the previous month (73% of grade I-II); 10 patients (11%) had had an infectious episode in the previous month and 16 (11%) currently had an infection; 14 patients (9%) had been diagnosed with chronic rejection. Three quarters of the patients were male. The most frequent cardiac disease was primary dilated cardiomyopathy, while fibrosis was the most prevalent diagnosis in lung transplantees. Half of the patients had attended school for less than 8 years; approximately 8% of the patients had been to university. Thirty-two percent of patients had been transplanted in the previous 2 years (heart 22%, lung 42%) and 39% more than 5 years before (heart 59%, lung 18%). Most patients had a good autonomy (going out alone 86%; climbing stairs 91%; driving a car 77%). Although almost half of the patients had resumed biking, less than 17% were practicing some type of sporting activity. All patients were able to perform and complete the walking test without interruption. Patients covered a median distance of 490 m, with little dyspnoea, as measured by the Borg scale.


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  		Table 1 Patient characteristics

 
One hundred and forty-eight patients (98%) filled out the QoL questionnaires. According to the GHQ, only about 20% of patients presented sign of psychological discomfort (score > 5), both overall and for each type of transplant. The mean SF36 PCS was 45 (47 in heart and 43 in lung recipients) and was significantly lower than the corresponding age and sex adjusted norm of 50 in the Italian population (p < 0.001, p = 0.002 and p < 0.001, overall, for heart and lung recipients, respectively). On the other hand, the SF36 MCS score was not lower (and sometimes higher) than the norm of 50, with overall and heart and lung recipient values of 51.3 (p = 0.078), 50.4 (p = 0.680) and 52.3 (p = 0.044), respectively. Lower than normal scores were observed for the single PF (p < 0.001), RP (p < 0.001), GH (p < 0.001) and RE (p = 0.003) dimensions (Fig. 1, top panel). The majority of patients in both groups rated their health from good to excellent as compared to the previous year (Fig. 1, bottom panel).


Figure 01
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  		Fig. 1 Quality of life as measured by the SF-36 questionnaire after heart (left) and lung (right) transplant. Top panels: normalized scores for the 8 dimensions of the SF-36, for MCS and PCS (for abbreviations see text). The dotted line at score 50 corresponds to the normal Italian population. Confidence Intervals above the dotted line correspond to significantly better QoL than the norm; Confidence Intervals below the dotted line correspond to significantly QoL than the norm. Confidence Intervals crossing the dotted line correspond to non significant difference in QoL with respect to the norm. Bottom panels: Distribution of answers to the additional question in the SF-36: "Compared to one year ago, how would you rate your health now?"

 
4.2. Working status
Fig. 2 illustrates the working status before and after transplant for the whole population. A minority of subjects (13%) were not employed before transplant. Of those in employment, 83% had to stop working due to their illness. After transplant, 51 patients resumed working, with a net loss to the work force of 61% (80 out of 131 initially employed patients; McNemar test p<0.001). However, 3 of the 20 patients who were not employed prior to transplant started to work. One patient (aged 36 years) had already retired and was on social support prior to transplant; 71 more patients retired and started on social support after transplant. The mean age of patients who retired was 56 years (SD 11); 25% were aged less than 52 years (25th percentile). Retirement rates were 48% among the 23 white collar workers, 30% among the 10 entrepreneurs/freelancers, 57% among the 67 blue-collar workers and 60% among the 25 self-employed workers (Fisher exact test p=0.003). Overall, patients tended to change their occupation after transplant (McNemar test p<0.001). However, while only 7 self-employed patients (28%) and 21 employees (23%) went back to the same occupation (seven of these were white collar (30%) and 14 blue collar (21%)), as many as 70% (7/10) of the entrepreneurs/freelance workers resumed the same occupation.


Figure 02
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  		Fig. 2 Flow chart to illustrate working status before and after transplant.

 
4.3. Determinants of return to work
Table 2 reports the results of the univariable analysis characterising the thoracic organ recipients who returned to work. Patients who returned to work were younger, had attended school for longer, enjoyed a higher degree of autonomy and mobility, covered a longer distance in the 6MWT with a lower rate of perceived dyspnoea. They had a better quality of life both in the physical and the mental domains. Being an entrepreneur/freelancer increased the likelihood of returning to work after the operation, as did having worked prior to transplantation (although not significantly). Moreover, patients who had been off work for more than 24 months before the transplant were less likely to return to work afterwards. Return to work was not related to sex, type of transplant (heart or lung), or to the length of time that had elapsed since the transplant. None of the transplant related complications (acute or chronic rejection/infection) appeared to be related to the rate of return to work in this stable population.


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  		Table 2 Determinants of return to work in heart and lung transplant recipients

 
Multivariable analysis (Table 2) revealed that MCS, age, previous occupation and being an entrepreneur/freelancer were independent predictors of return to work (the validation statistics, c and shrinkage, indicate that the model works sufficiently well). In a second multivariate model on fewer patients (105 patients in whom the information was available), it was found that those patients who had been off work for more than 24 months before the operation were less likely to return to work, regardless of other factors (OR 0.26; 95%CI 0.08-0.79; p=0.017), as were patients older than 50 years (OR=0.2; 95%CI 0.09-0.88; p=0.030 and patients with a lower MCS (OR=1.07; 95%CI 1.01-1.15; p=0.035).


   5. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistical analysis
 4. Results
 5. Discussion
6. Conclusion
 References
 
This study assessed the rate of return to work as well as its determinants in a population of patients who had undergone lung and/or heart transplant at least 6 months before, and who were sufficiently stable to require only routine check-ups. These characteristics were selected in order to identify a population who were likely to be eligible to return work. We included clinically-stable patients of working age (mean age of 50 years), approximately 90% of whom regained good levels of autonomy and mobility (going out on their own, walking, climbing stairs, driving). To our knowledge this is one of the few studies to examine this problem in recent years [21], in a large single centre population. Our survey revealed that the average distance covered in the 6MWT was higher than that reported for patients with chronic heart failure or end-stage lung disease [22,23], but lower than that walked by healthy subjects of the same age: the distance walked was within the reference range reported for the healthy population, albeit for older age groups [24]. Moreover, our survey indicates that perceived physical well-being, explored by the Physical Component Summary (PCS) of the SF 36, was below normal levels reported for the healthy Italian population, whereas the mental dimension of the SF 36 (MCS) and GHQ score ratings indicated that patients enjoyed good mental health. Besides increasing survival rates, organ transplantation undoubtedly improves quality of life, seen also as an active participation in the social field and as personal achievements [1-3,25,26]. In our opinion, these data clearly define a patient who makes a good functional recovery and who is able to reinstate himself in the social field and at work.

However, despite the good clinical condition of the selected population, our data show that of the 131 patients who had an occupation before their transplant, only 39% resumed working, and only 15% of patients without a previous occupation started working after their transplant. No difference was observed between heart or lung transplant recipients, nor according to the time elapsed since transplant. The latter observation is in agreement with a retrospective analysis of 62 heart transplant recipients [8], where no substantial differences were found in the rate of return to work 1, 5, or 12 years after transplantation.

The prevalence of return to work after heart or lung transplantation reported in the literature is extremely variable, ranging from about 20 to 80% [2,5,6,8,9,11,21,27,28]. Our data are towards the lower limit of this range. In view of their good, objective and subjective, functional status, we believe that there are a number of patients who could return to work (even considering their age), but who do not, due to lack of opportunity, individual uneasiness or lowered self-esteem. Also, the Italian welfare system, which guarantees social support to everybody, might in part be responsible for this low rate of return to work. In fact, half our population had retired and were on social support despite their age, good functional recovery and quality of life. The observed rate of return to work in this population, who regained good levels of autonomy and mobility and fair to good quality of life, emphasises the importance of informing patients on the transplant waiting list that surgery can lead to sufficient functional recovery to enable them to return to work. A well-informed patient is further motivated to accept and follow any necessary treatment.

However, considering the high number of patients who stopped working due to disease (109 out of 131), having 39% of patients resuming work can be considered as an achievement per se. A better insight into the determinants of such a return might help to increase the prevalence of transplantees working, with a benefit for both society and the individual.

Many reasons for the reduced rate of return to work are cited in the literature, these include changes of priority, hiring discrimination on the basis of medical history, restrictive cost or unavailability of health insurance, poor local or regional economic conditions, limited education or work skills and the recipient's perception that these obstacles are insurmountable, and also the length of time spent off work before transplantation [2,8-11]. Moreover, previous studies have shown that return to work is lower amongst blue-collar workers whose work is physically more demanding [21]. Our findings are in accordance with these data and with other data from patients having undergone major surgery (e.g. coronary artery bypass graft) [29,30]. We found that younger age, a better quality of life (mainly in the mental domain), having had an occupation in the past, particularly as an entrepreneur/freelancer, and (in a subgroup of patients with available information) having been off work for less than 24 months, were independent predictors of return to work. Entrepreneurs and freelancers who tended to return to work more often than self-employed patients, blue and white collars, were also those who more often resumed the same occupation. This could be related to factors such as the determination to return to work, salary, job satisfaction, and the ability to organise one's personal health care (periodic check-ups, distance between home and hospital), which better apply to entrepreneurs and freelancers, and fear of exposure to potential risks in the workplace, which could endanger personal health, a concern which is likely to be more frequent in blue-collar workers. A better functional recovery, as measured by the distance walked at the 6MWT, although associated with return to work at the univariable analysis, did not have independent prognostic ability in the multivariable model. This is in keeping with the observation that the decision whether or not to return to work cannot be considered a decisive factor in establishing a patient's degree of disability, which is a combination of more specific measures.

We only report the rate of return to work and its determinants in a selected population of transplantees, who were likely to resume their working life in view of their good clinical condition. As such, we did not report, and we did not aim to report, the overall rate of return to work of the entire population of patients undergoing transplantation of a thoracic organ at our Institution. This might be considered a limitation to our study from a public health perspective, although we believe return to work to be a relevant issue for the individual patient and for his/her health care providers.


   6. Conclusion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistical analysis
 4. Results
 5. Discussion
 6. Conclusion
References
 
Heart and lung transplantation are associated with increasing rates of survival, good functional recovery and quality of life. Return to work could be expected as part of this recovery, but this is not always the case. Several factors affecting return to work may be identified, and these might help health professionals to adopt the best course of treatment and psychological support in order to fulfil this goal. However, we should not regard return to work as the only expression of a patient's real psychophysical condition. After a long period of illness and the prospect of death, post transplant patients tend to attach importance to factors other than work, giving priority to relationships with family and friends, spirituality and free time.


   Acknowledgements
 
We thank Karen Doyle for revising the English in this manuscript.

This work was supported in part by a grant for the "Ricerca Corrente", Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Statistical analysis
 4. Results
 5. Discussion
 6. Conclusion
 References
 

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