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Employment After Liver Transplantation: A Review
Employment After Liver Transplantation: A Review A. Hudaa,b,*, R. Newcomerc, C. Harringtond, E.B. Keeffeb, and C.O. Esquivela a Division of Abdominal Transplantation, and bDivision of Gastroenterology and Hepatology, Department of Medicine, Stanford University Medical Center, Stanford, California; and cInstitute for Health and Aging and dDepartment of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California
ABSTRACT Background. Return to productive employment is often an important milestone in the recovery and rehabilitation process after liver transplantation (OLT). This literature review identifies factors associated with employment in patients who underwent OLT. Methods. We searched PubMed for articles that addressed the various factors affecting employment after OLT. Results. The studies demonstrated improvement in the quality of life and examined factors that predicted whether patients would return to work after OLT. Demographic variable associated with posttransplant employment included young age, male sex, college degree, Caucasian race, and pretransplant employment. Patients with alcohol-related liver disease had a significantly lower rate of employment than did those with other etiologies of liver disease. Recipients who were employed after transplantation had a significantly better posttransplant functional status than did those who were not employed. Conclusion. Economic pressures are increasing the expectation that patients who undergo successful OLT will return to work. Thus, transplant teams need to have a better understanding of posttransplant work outcomes for this vulnerable population, and greater attention must be paid to the full social rehabilitation of transplant recipients. Specific interventions for OLT recipients should be designed to evaluate and change their health perceptions and encourage their return to work.
O
RTHOTROPIC LIVER TRANSPLANTATION (OLT) has become the treatment of choice for many patients with end-stage liver disease. The goal of transplantation is to maximize both the length and quality of life of the patient, while minimizing the effects of the disease and costs of care. Short-term posttransplant survival is exceptionally high at just under 90%. Transplantation professionals are shifting their focus to achieve long-term survival, free of morbidity, in association with an acceptable quality of life [1]. Traditionally, the success of OLT has been measured by 1-, 3-, and 5-year survival rates. Over the past 35 years, advances in medical and surgical therapies have dramatically improved posttransplant outcomes. Specifically, the introduction of calcineurin inhibitors, cyclosporine, and tacrolimus have revolutionized solid organ transplantation by decreasing acute and chronic allograft rejection and, consequently, improving patient and graft survival. The population of long-term survivors after OLT is now 10-fold greater than the number of transplantations performed
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Transplantation Proceedings, 47, 233e239 (2015)
each year. In addition to prolonging survival, a substantial number of studies have found that OLT improves recipient quality of life [2e6]. Ultimately, outcomes of OLT will need to be judged not only by survival, but also by the number of quality life-years restored, a measure that incorporates both survival rate and the quality of the time survived. Among the quality of life indicators of interest to physicians and policy makers is the impact of OLT on postoperative employment. Several factors may be associated with unemployment after liver transplant surgery. About two-thirds of patients who have received a liver transplant and have done well medically, nevertheless, do not become employed after the procedure [7]. Posttransplant unemployment has been associated with poor health, disability status, early *Address correspondence to Amina Huda, NP, PhD, Division of Abdominal Transplantation, Stanford University Medical Center, 750 Welch Rd., Suite 319 e MC 5731, Palo Alto, CA 94304. E-mail: [email protected] 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2014.10.022
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retirement, and fear of losing disability or Medicaid benefits [8,9]. Examination of factors that might influence employment status among working-age liver transplant recipients is particularly important given the economic downturn of the last few years. Unemployment has consistently surpassed 8% since mid2009 and remains more than double the rate of 10 years ago [10]. Liver transplant recipients and other individuals with chronic disease have increased risk of unemployment compared with the general population for a variety of reasons, including severity of illness, work-related factors, and available social support [11,12]. Further, >$955 billion in lost productivity annually is attributable to chronic disease states. Well-designed prevention and treatment efforts that increase employment opportunities and capacity are needed to reduce the burden of chronic diseases and alleviate their negative economic consequences [13]. One step toward the development of these efforts is a better understanding of factors that may act as potential barriers to employment. Toward this end, this article reviews and summarizes studies of posttransplantation outcomes with the aim of highlighting issues that affect transplant recipients’ employment statuses. FACTORS ASSOCIATED WITH EMPLOYMENT AFTER OLT Age
Several studies evaluated employment after OLT of those 18 years, of whom more than one-half showed significant data [8,14e18]. A study by Loinaz et al [15] provided a detailed evaluation of employment patterns of 137 patients before and after OLT at a center in Madrid, Spain. Fifty-six patients (41%) returned to work 2.6 months, on average, after transplantation. Patients <50 years old and those who had worked within 12 months pretransplantation were significantly (P ¼ .004) more likely to return to work than were patients >50 years who had been unemployed for 1 year before transplantation. In another single-center study in Canada, Adams et al [16] concluded that recipient age was related to the likelihood of returning to work. The found the mean age of employed patients was significantly younger than unemployed patients (41.7 1.2 vs 49.6 1.3 years; P ¼ .0001). Huda et al [17] examined factors that affected employment status in 21,942 OLT recipients. The study used the United Network for Organ Sharing data registry to determine the proportions of recipients who were employed and unemployed within 24 months after OLT between 2002 and 2008. Approximately one-quarter of OLT recipients (5360 [24%]) were employed within 24 months after OLT; the remaining recipients had not returned to work. The study found that patients who were >40 years old were less likely to be employed after OLT than were patients 40 years old (odds ratio [OR], 0.72; P ¼ .0001). In another single-center study from the Mayo Clinic, Rongey et al [8] examined 186 adult OLT recipients who survived for 1 year after OLT. The employment rate was higher for OLT recipients who
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were <65 years of age (61%); only 26% of those 65 years old were employed. Only 2 studies [9,19] concluded that age was not a predictor of returning to work after transplantation; however, sample sizes in those studies were small. Although the literature generally reports that younger transplant recipients are more likely to work after transplantation than are older recipients, the causal factors are complicated by the fact that older patients are more likely than younger patients to seek early retirement, rather than employment. Moreover, published studies have not identified fully the reasons why many younger, healthy transplant recipients do not return to work. For example, it is possible that younger, compared with older, transplant recipients have higher incidences of alcohol abuse and/or drug dependency, which might result in a somewhat lower employment rates if employers are reluctant to hire patients with a history of substance abuse. Further attention to employment outcomes in transplant populations, particularly in younger recipients, will be important to research. Gender
Researchers have not examined the effects of gender on post-OLT employment extensively. Cowling et al [20] studied 88 male and 61 female OLT recipients. Recipients completed a questionnaire at their pretransplant evaluation and again at their 1- and 2-year follow-up visits at Baylor University Medical Center. The study found a significantly greater percentage of men, compared with women, who reported current employment at pretransplant evaluation (P ¼ .001) and again at the 1-year after OLT (P ¼ .019). By the second year, employment rates between the sexes were similar. Gorevski et al [19] examined factors that affected depression and employment status among 91 OLT recipients. The study found that a significantly greater percentage of men, compared with women, were employed after OLT (OR, 4.1; P ¼ .04). Huda et al [17] supported these findings and found that females were 0.57 times less likely than were males to be employed after OLT (P ¼ .0001). In contrast, Hunt et al [10] study of 52 patients compared those who were employed (60%; n ¼ 31) posttransplantation to those who were not. They found no difference in gender between patients who were employed or unemployed posttransplantation. The mixed findings presented here are in part related to a definitional issue in which “work” is considered synonymous with employment. Few articles have discussed and distinguished the contributions of household workers [16,21]. For example, Adams et al [16] and Newton [21] used a definition that categorized homemakers and students as “employed” if they had returned to their same pretransplant roles. Such a definition substantially affects the results. Newton found that, after OLT, 63% of recipients were working for either pay or in one of these other roles. Using the classic definition of work as paid employment would have resulted in a return-to-work rate of 36%. Another study by Newton [22], again defining work to
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Table 1. Employment Rates by Gender
differences on employment rates at either 1 or 2 years posttransplantation. Some earlier work has found little association among samples in which >60% of the study sample was employed after OLT [9,21]. In the case of the Hunt et al [9] study, the absence of an education effect was attributed to the small sample size (52 patients). The Newton [21] study was larger (230 patients), making the finding of no education effect more difficult to ignore. Two studies in this same period found that employed patients tended to be better educated [14,20].
Author
Sample
Male
Female
Employment (%)
Adams [16] Hunt [9] Huda [17] Loinaz [15] Saab [18] Sahota [23]
203 52 21,942 137 308 105
79 34 15,474 90 181 66
124 18 6468 47 127 49
57 60 24 41 26 49
include both employment and household work, found that 59% of female alcoholic liver transplant recipients worked after OLT, including 17% who reported that they were household workers. The employment rate after OLT, as reported in published studies, is shown in Table 1.
Employment Status Before Transplantation
Racial disparities in posttransplant care and outcomes are not well studied. One reason may be racial barriers to OLT [24]. For example, in 2005, 6.8% of all patients on the liver transplant (OLT) waiting list and 9.4% of OLT recipients were African American. These rates contrast with the US population, where African Americans comprise 12.9% of the total population. Underrepresentation does not seem to be a factor for the Hispanic population. The fraction of Hispanic patients on the OLT waiting list (16%) has nearly tripled in the last decade. Hispanics constitute 13% of OLT recipients and 12.5% of the US population [25]. Another factor is that studies typically have not over sampled race/ ethnic groups to ensure adequate sample sizes. Reflective of this, only 3 studies explicitly evaluated the association between race/ethnicity and employment posttransplantation [9,17,18]. Studies conducted by Hunt et al [9] and Saab et al [18], which attempted to look at this issue, did not find a difference in race/ethnicity in terms of employment rates posttransplantation; however, their sample sizes were small. For example, the Hunt et al study included 52 patients [9]. Huda et al are an exception in the literature in their work with the United Network for Organ Sharing dataset [17], which yielded a significant race/ethnicity difference between Hispanics and whites. Hispanics were 0.58 times less likely than whites to be employed after transplantation. The cause of this difference could not be determined in the data available to these investigators.
Pretransplant employment status is a highly predictive main effect of whether patients return to work. Rongey et al [8] examined employment status among 186 long-term OLT recipients. Ninety-eight patients were employed posttransplantation. Those with employment before transplantation had substantially higher odds (5:1) of returning to work did than those without a prior work history. Huda et al [17] came to the same conclusion in a large national study (n ¼ 21,942). These authors found that patients who worked before OLT were 4.8 times more likely to be employed after transplantation than those who did not work before transplantation. This study did not have specific employment information for patients beyond the period immediately before the OLT. It is possible that patients who have been out of the workforce for long periods “unemployed” before OLT. Sahota et al [23] provided information about individuals who worked during the 5 years before OLT, and found that they were more likely to return to work than those who did not work during this interval. However, even in this study, patients who had held a job for >6 months before OLT were the most likely to return to employment. Prior occupation is another factor. Patients such as farm workers or unskilled laborers who held “low-skill” and more physically demanding jobs were less likely to return to work than were executives, administrators, managers, or technicians. The differentiation of occupation effects was also reported in earlier work by Adams et al [16]. That study found OLT recipients who worked in nonoffice jobs were significantly less likely to return to work after transplantation than were patients who held office jobs.
Education
Health Status/Functional Status
Employment after OLT has been studied regarding the impact of educational level. More recent studies tend to report that years of education attained before OLT has a significant effect on employment after transplantation [14,17,23,26]. Cowling et al [26] used a prospective design with 88 male and 61 female OLT recipients and found that more educated men (>12 years of schooling) reported higher employment rates than did their lesser educated counterparts (<12 years) at 1 and 2 years after transplantation (45% vs 19%, respectively). Among women, the findings revealed no influence of educational
Health status has been widely used when examining influences on returning to work. Adams et al [16] used the Sickness Impact Profile to study 217 patients who had undergone OLT and survived for 9 months. The researchers compared patients who were employed posttransplantation with those who were not. They found that the employed group was younger, had shorter pretransplantation disability, and had significantly lower Sickness Impact Profile scores in the areas of ambulation, home management, physical function, and pain than did those who remained unemployed. Hunt et al [9] reported that, when
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patients were queried about the most important factor preventing their return to work, 80% cited “problems with their health.” In a study of 186 liver transplant recipients, Rongey et al [8] also showed that poor health was the most common reason for unemployment. A large cohort study (n ¼ 21,942) from Huda et al [17] reported that patients with limited functional status were less likely to work after transplantation than were patients with no functional limitations. Pretransplant physical/functional status can greatly influence the ability to perform activities of daily living post transplantation. Patients with end-stage liver disease may be confined to the hospital, unable to walk short distances, or/ and inotrope dependentdall of which contribute to severe deconditioning. Although these conditions may prolong rehabilitation of the patient and, therefore, prolong the period before returning to work or preventing them from working, these attributes have not been included in measures of health status. However, a Danish study conducted by Aadahl et al [27] assessed fatigue and physical function after OLT. Their study used the 36-Item Short Form Health Survey (SF-36), Multidimensional Fatigue Inventory (MFI20), and Hospital Anxiety and Depression Scale with a sample of 130 OLT recipients. The finding revealed that Danish OLT recipients did not differ from the general population on mental health, but did differ on all physical and social health dimensions. The researchers also found that patients who were not working (n ¼ 70) had poorer physical function (SF-36 score, 64 25) and more physical fatigue (MFI-20 score, 57 34) than did patients who were either working or studying (n ¼ 60; SF-36, 90 14; MFI-20, 31 26). Saab et al [18] also used the SF-36 to study employment and quality of life of post-OLT patients (n ¼ 316). All SF-36 domains collected posttransplantation were significantly lower in the OLT cohort compared with the general population (P .001). Two domains were significantly associated with posttransplantation unemployment: physical functioning (OR, 1.17; P .01), which assesses limitations in physical activities because of health problems, and role physical (OR, 1.1; P .01), which assesses limitations in usual role activities because of physical health problems. Mental health had no association with employment (OR, 0.98; P .09). The reviewed studies found that poor post-OLT physical health and disability were associated with posttransplantation employment status. However, no study categorized the reasons for poor health. The prevalence and severity of specific symptoms and problems after OLT have not been addressed sufficiently by the generic questionnaires used in the reviewed studies. In addition, information about whether quality of life was improved by OLT is limited. Model for End-Stage Liver Disease Score
The Model for End-Stage Liver Disease (MELD) score was originally proposed as a means to predict short-term mortality in patients with end-stage liver disease. In clinical
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practice, the MELD score is often used as an overall indicator of the patient’s functional health status. Three studies found evaluated employment after OLT adjusting for preOLT MELD scores. Sahota et al [23] (n ¼ 105) investigated the correlation between posttransplant employment and clinical variables (eg, etiology of liver disease, MELD score) before and after OLT. The study found no association between the severity of clinical status before and after OLT and employment. Saab et al [18] (n ¼ 308) similarly found that MELD scores were not predictive of posttransplant employment. A large, national study [17] using the United Network for Organ Sharing date registry found the proportion of employed patients with a pretransplant MELD score of <21 was slightly higher than the proportion of patients who were not employed after transplantation. However, this relationship did not attain significance after adjustments for all other study covariates. Huda et al [17] recognized that the MELD scores of patients with hepatocellular carcinoma could be calculated based on the laboratory values alone or with the inclusion of exception status scores. They conducted a separate analysis to assess the sensitivity of the results to this classification choice. Using the laboratory-based MELD score increased the number of patients with a MELD score of <21 and decreased the number of patients with scores ranging from 22 to 31. There was little change in the number of patients with MELD scores of <31. The MELD score ORs from the models predicting post OLT employment status were similar in magnitude and were non-significant in both sets of models. Alcohol-Related Liver Diseases Versus NoneAlcohol Related Liver Diseases
A University of Michigan study (n ¼ 122) by Newton [22] examined the difference between those with alcoholrelated liver disease (ALD) and those with other causes. The sample consisted of 47 ALD women, 60 non-ALD women, 48 ALD men, and 20 non-ALD men. The study showed that female ALD recipients’ post-OLT work outcomes were similar to those of female non-ALD recipients. Moreover, female ALD recipients returned to work at rates higher than either the ALD (52%) or the non-ALD male recipients (56%). This somewhat high return to work rate among females could be owing to the inclusion of household workers within the definition of work. Ten ALD recipients (all female) who returned to work posttransplant were household workers. Some studies have found no ALD effects on post-OLT employment. Nicholas et al [28] found that history of alcohol use did not influence recipient employment after transplantation. Cowling et al [20] supported these findings in a study of 84 ALD and 68 non-ALD recipients; all had undergone OLT at a single, urban teaching hospital. The specific objective of the study was to describe and qualify liver transplant recipients’ societal reintegration after OLT. The researchers also compared the degree of societal reintegration between individuals transplanted for ALD and non-ALD liver disease. No difference between groups was
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Table 2. Employment Rates by ALD and Non-ALD Author
Sample
ALD (n)
Non-ALD (n)
Employment (%)
ALD Employment (%)
Non-ALD Employment (%)
Cowling [26] Huda [17] Newton [22] Pageaux [29]
152 21,942 122 39
84 4,497 95 22
68 17,445 80 17
36 24 55 44
33 21 59 30
38 79 62 60
Abbreviation: ALD, alcohol-related liver diseases.
noted in the proportion of subjects employed. Nearly 70% of employed individuals in both groups reported working 40 hours per week. A French study yielded very different findings [29]; 30% of ALD patients and 60% of non-ALD patients returned to employment posttransplantation. The significant difference between ALD patients and non-ALD patients seems to be related to the level of occupation before transplantation. Pre-OLT employment rates were lower among ALD patients than non-ALD patients. The poorer medical conditions of patients with ALD (81% Child-Pugh’s score C) than those with non-ALD (63% Child-Pugh’s score C) before transplantation may have also contributed to this discrepancy. Huda et al [17], using a US national transplant registry dataset, supported the French results. Their study showed that patients with non-ALD were 63% more likely than patients with ALD to work after transplantation, after adjusting for MELD scores and pre-OLT employment status. A summary of the influence of ALD on employment after OLT is shown in Table 2. The comparison of these studies suggests that slightly fewer patients with ALD than non-ALD worked at 1 year. A potentially confounding factor in these studies is that the mean age of transplant recipients with non-ALD was significantly younger than that of transplant recipients with ALD. Because no study reviewed described the nature of employment (beyond whether full time or part time), it could not be determined whether patients returned to the same or equivalent jobs. Medical Insurance
Health insurance is closely tied to employment in the United States, because most private insurance is obtained through the workplace. Fear of insurance loss may act as an incentive for individuals seeking employment. Likewise, the cost of insurance for those with histories of OLT may be a disincentive for employers asked to hire OLT recipients. A third consideration is that those with government medical insurance such as Medicaid may lose coverage if they have gainful employment with incomes above the Medicaid income qualification thresholds. Hunt et al provided support for the idea that Medicaid recipients may have an incentive to remain unemployed [9]. Patients insured by Medicaid before transplantation were 1.7 times more likely to remain unemployed after transplantation than were those with other forms of insurance. For those patients returning to work after transplantation, 19 of 31 (61%) returned to the same job.
In contrast with these findings, Rongey et al [8] examined factors that affect health insurance and employment status in 186 long-term liver transplant recipients, and found no relationship. Almost one-half of these patients (n ¼ 98) were employed posttransplant. In this sample, all but 3 individuals had health insurance of some type. This included 18% who received their insurance through their spouse, 38% reporting having >1 source of health insurance coverage, 55% with their own private insurance, and 36% with public insurance (ie, Medicare, Medicaid, Veteran’s Administration, or Native American programs). Disability Benefits
Saab et al [18] showed that the lack of disability insurance before transplantation (OR, 0.50; 95% CI, 0.24e0.10; P ¼ .05) was independently and significantly associated with posttransplantation employment. Rongey et al [8] yielded a similar finding; 12% indicated that they were able to work, but were afraid to do so for fear of losing their disability benefits. The authors did not find any association between Medicaid and unemployment. Sahota et al [23] conducted a cross-sectional study of OLT recipients to investigate the association between patients’ socioeconomic and quality-of-life parameters and employment status after transplant. The researchers noted that patients who received Social Security Disability Benefits for >6 months were less likely to return to work after transplantation. Among patients who were not working after OLT, 65% cited poor health and 20% cited loss of health insurance coverage if they returned to work as reasons for not working. The duration of disability before transplantation also influences posttransplant employment. An early study of employment after OLT from the University Hospital of Ontario, Canada found that 40% of OLT recipients were employed full time after transplantation [17]. Seventeen percent of patients were employed part time and 43% of patients were unemployed. The authors found that the duration of disability before transplantation had a significant effect on posttransplantation employment status. Only 33.6% of patients who had not worked in the 5 years before receiving their transplant returned to work, whereas 75% who had worked during this period were employed after transplant (P .0001). Similarly, the mean period of pretransplantation disability was significantly less among the employed patients compared with the unemployed patients (P .01) [16]. It seems that the longer the disability period pretransplantation, the more difficult it is for recipients to return to work post transplantation.
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Studies to date have not fully distinguished the extent to which employment rates after OLT are related to physical disabilities or the financial burdens that develop with the loss of disability benefits. Moreover, legislation has changed over the years to help patients overcome post-OLT financial burdens that may lead to more encouraging employment outcomes for the OLT population. For example, a Medicaid program, “Ticket to Work,” is designed to assist transplant patients to secure employment after surgery. In addition, Medicaid allows a buy-in program that encourages persons with a disability to work and retain their health care coverage through Medicaid. Research in countries with universal health care could provide a helpful natural experiment in separating the effects of health insurance coverage and health status on posttransplant employment. However, even in these situations, the potential confounding effect of income available through disability insurance or social programs, and the extent to which employment affects access to or loss of these benefits remains to be examined. Geography
Another variable that may influence an individual’s return to work after OLT is where someone lives. Data from some of the most representative studies performed across different regions of the United States are shown in Table 3. These studies reveal considerable variation in employment rates after OLT. Some of this variation seems to be attributable to local economic conditions that are subject to change over time. For example, a 60% employment rate after OLT was found in North Carolina, a state with a growing economy [9]. In contrast, Saab et al [18] found a 27% employment rate during a period of poor economic conditions and a high unemployment rate in the United States. Similarly, a low employment rate (36%) was reported in a Texas study [26], which was conducted during a period of high unemployment. These rates of unemployment, even in the best circumstances, contrast the prevailing unemployment rates of 4%e8% found in the United States during the late 1990s and early 2000s. Attitudes of Potential Employers
Employers’ attitudes toward transplant recipients may also be a barrier to returning to work [30,31]. One factor affecting attitudes is that employment is a common vehicle for obtaining health insurance coverage. A transplant recipient may be Table 3. Influence of Geographic Region on Employment Rates After Liver Transplantation in the United States Author
States
Sample
Employment (%)
Cowling [26] Hunt [9] Newton [21] Rongey [8] Saab [18] Sahota [23] Huda [17]
Texas North Carolina Michigan Minnesota California California All States
152 52 122 217 308 105 21,942
36 60 55 55 27 42 24
deemed too “high risk” for employment-based health insurance. The latter is especially true for businesses that lack a large pool of employees to disperse the burden of high costs associated with organ transplantation without increasing overall health insurance costs. A Mayo Clinic study on health insurance and post-OLT employment found that of 179 respondents, 10 reported that they were denied (6%) and another 6 were terminated from (3%) employment because of their transplant [8]. Similar findings were reported in a more recent post-OLT employment and quality-of-life study. Of 308 adult OLT recipients, 13 reported having been denied employment because of their transplant [18]. The reviewed studies have found employment rates among OLT recipients ranging from 22% to 60%. These rates vary widely for a number of reasons; among them is the lack of uniformity in the time from OLT and exclusion criteria used to define the study samples. Furthermore, studies on returning to work after OLT were conducted in single centers with small patient cohorts and were specific to limited time periods. Despite these limitations, a common conclusion is evident: Social rehabilitation, at least as measured after OLT, lags behind the medical results of transplantation. The combined factors of age, length of pretransplant disability, pretransplant dependence on government financial assistance, self-reported health status of not being able to work, and <6 months posttransplant seemed to be barriers that prohibited many recipients who were not medically disabled from returning to work. The majority of posttransplant employment studies were descriptive, and none were trials or evaluations of efforts designed to increase employment. Many studies on quality of life after OLT have potential biases. Commonly, they excluded the very ill or recipients considered “unemployable” by the investigators. Another limitation was the absence of a uniform sampling designs. This includes the absence of overweighting of special groups, namely race/ethnic minorities, different subgroups defined by pretransplant education and work histories, persons eligible for disability benefits and health insurance after the OLT, and inconsistency among studies concerning the pretransplant and posttransplant study periods. Also, little consistency exists in the measures used to define such basic items as employment, health status, functional limitations, education, work experience, and jobseeking behaviors. Studies also do not differentiate, either in the sample plan or outcomes, between transplant recipients who returned to the jobs they held before transplantation or those seeking other positions, between full- or part-time positions, or between full-time students and housewives as alternative statuses of employed. More rigorous, prospective studies need to be performed that examine predictors of unemployment using multivariable analyses would be recommended. Previous work has helped to identify factors associated with employment, and the measurement and sample design issues that need consideration. This work has also shown that age, college degree, pretransplant employment, and post-OLT health status are important correlates of employment. Transplant teams need to build off
EMPLOYMENT AFTER LIVER TRANSPLANTATION
of this experience and begin to formulate full social rehabilitation programs for transplant recipients. Specific interventions might be developed to change recipients’ health perceptions and include occupational counseling and job referrals. One practical issue is whether studies and interventions should be tailored separately for white collar and more physically demanding occupations. There is also a policy question of understanding how disability benefits (including income support) and health insurance operate as either incentives or disincentives for employment. The implementation of the Affordable Care Act, with the elimination of preexisting condition restrictions, may prove helpful in reducing barriers to employment. REFERENCES [1] Karam V, Castaing D, Danet C, et al. Longitudinal prospective evaluation of quality of life in adult patients before and one year after liver transplantation. Liver Transpl 2003;9:703e11. [2] Belle SH, Porayko MF, Hoofnagle JH, et al. Changes in quality of life after liver transplantation among adults. National Institute of Diabetes and Kidney Diseases (NIDDK) Liver Transplantation Database (LTD). Liver Transpl Surg 1997;3:93e104. [3] Bravata D, Olkinn I, Barnato A, et al. Health-related quality of life after liver transplantation: a metaanalysis. Liver Transpl Surg 1999;5:318e31. [4] Caccamo L, Azara V, Dogila M, et al. Longitudinal perspective measurement of the quality of life before and after liver transplantation among adults. Transplant Proc 2001;33:1880e1. [5] Gross CR, Malinchoc M, Kim WR, et al. Quality of life before and after liver transplantation for cholestatic liver disease. Hepatology 1999;29:356e64. [6] Tarter RE, Switala J, Arria A, et al. Quality of life before and after orthotopic liver transplantation. Arch Intern Med 1991;151: 1521e6. [7] Bravata D, Keeffe EB. Quality of life and employment after liver transplantation. Liver Transpl 2001;7:S119e23. [8] Rongey C, Bambha K, Vanness D, et al. Employment and health insurance in long term liver transplant recipients. Am J Transplant 2005;5:1901e8. [9] Hunt CM, Tart JS, Dowdy E, et al. Effect of orthotopic liver transplantation on employment and health status. Liver Transpl Surg 1996;2:148e53. [10] Bureau of Labor Statistics. Labor force statistics from the current population survey. U.S. Department of Labor. Available at http://data.bls.gov. Accessed April 14, 2011. [11] Varekamp I, Verbeek JH, van Dijk FJ. How can we help employees with chronic diseases to stay at work? A review of interventions aimed at job retention and based on an empowerment perspective. Int Arch Occup Envrion Health 2006;80:87e97. [12] Grammenos S. Illness, disability, and social inclusion. European Foundation for the Improvement of Living and Working Conditions; 2003. Available at, http://www.eurofound.europa.eu. Accessed April 15, 2011.
239 [13] Devol R, Bedroussian A. An unhealthy America: the economic burden of chronic disease. Milken Institute; 2007. Available at, http://www.milkeninstitute.org. Accessed April 18, 2011. [14] Moyzes D, Walter M, Rose M, et al. Return to work 5 years after liver transplantation. Transplant Proc 2001;33:2878e80. [15] Loinaz C, Clemares M, Marqués E, et al. Labor status of 137 patients with liver transplantation. Transplant Proc 1999;31: 2470e1. [16] Adams PC, Ghent CN, Grant DR, et al. Employment after liver transplantation. Hepatology 1995;21:140e4. [17] Huda A, Newcomer R, Harrington C, et al. High rate of unemployment after liver transplantation: analysis of the United Network for Organ Sharing database. Liver Transpl 2012;18: 89e99. [18] Saab S, Wiese C, Ibrahim AB, et al. Employment and quality of life in liver transplant recipients. Liver Transpl 2007;13: 1330e8. [19] Gorevski E, Succop P, Sachdeva J, et al. Factors influencing posttransplantation employment: does depression have an impact? Transplant Proc 2011;43:3835e9. [20] Cowling T, Jennings LW, Goldstein RM, et al. Liver transplantation and health related quality of life: scoring differences between men and women. Liver Transpl 2004;10:88e96. [21] Newton SE. Relationship of hardiness and sense of coherence to post liver transplant return to work. Holist Nurs Pract 1999;13:71e9. [22] Newton SE. Work outcomes for female liver transplant recipients with alcohol related liver disease. Gastroenterol Nurs 2001;24:288e93. [23] Sahota A, Zaghla H, Adkins R, et al. Predictors of employment after liver transplantation. Clin Transplant 2006;20: 490e5. [24] Reid A, Resnick M, Chang Y. Disparity in use of orthotopic liver transplantation among blacks and whites. Liver Transpl 2004;10:834e41. [25] Pomfret E, Fryer J, Sima C. Liver and intestine transplantation in the United States, 1998-2005. Am J Transplant 2007;7: 1376e89. [26] Cowling T, Jennings LW, Goldstein RM, et al. Societal reintegration after liver transplantation: findings in alcohol related and non-alcohol related transplant recipients. Ann Surg 2004;239: 93e8. [27] Aadahl M, Hansen BA, Kirkegaard P, et al. Fatigue and physical function after orthotopic liver transplantation. Liver Transpl 2002;8:251e9. [28] Nicholas J, Oleske D, Robinson L, et al. The quality of life after orthotopic liver transplantation: an analysis of 166 cases. Arch Phys Med Rehabil 1994;75:431e5. [29] Pageaux G, Michel J, Perney P, et al. Alcoholic cirrhosis is a good indication for liver transplantation, even for cases of recidivism. Gut 1999;45:421e6. [30] Commander M, Neuberger J, Dean C. Psychiatric and social consequences of liver transplantation. Transplantation 1992;53: 1038e40. [31] Heyink J, Tymstra T, Sloof MJ, et al. Liver transplantationepsychosocial problems following the operation. Transplantation 1990;49:1018e9.
ABSTRACT Background. Return to productive employment is often an important milestone in the recovery and rehabilitation process after liver transplantation (OLT). This literature review identifies factors associated with employment in patients who underwent OLT. Methods. We searched PubMed for articles that addressed the various factors affecting employment after OLT. Results. The studies demonstrated improvement in the quality of life and examined factors that predicted whether patients would return to work after OLT. Demographic variable associated with posttransplant employment included young age, male sex, college degree, Caucasian race, and pretransplant employment. Patients with alcohol-related liver disease had a significantly lower rate of employment than did those with other etiologies of liver disease. Recipients who were employed after transplantation had a significantly better posttransplant functional status than did those who were not employed. Conclusion. Economic pressures are increasing the expectation that patients who undergo successful OLT will return to work. Thus, transplant teams need to have a better understanding of posttransplant work outcomes for this vulnerable population, and greater attention must be paid to the full social rehabilitation of transplant recipients. Specific interventions for OLT recipients should be designed to evaluate and change their health perceptions and encourage their return to work.
O
RTHOTROPIC LIVER TRANSPLANTATION (OLT) has become the treatment of choice for many patients with end-stage liver disease. The goal of transplantation is to maximize both the length and quality of life of the patient, while minimizing the effects of the disease and costs of care. Short-term posttransplant survival is exceptionally high at just under 90%. Transplantation professionals are shifting their focus to achieve long-term survival, free of morbidity, in association with an acceptable quality of life [1]. Traditionally, the success of OLT has been measured by 1-, 3-, and 5-year survival rates. Over the past 35 years, advances in medical and surgical therapies have dramatically improved posttransplant outcomes. Specifically, the introduction of calcineurin inhibitors, cyclosporine, and tacrolimus have revolutionized solid organ transplantation by decreasing acute and chronic allograft rejection and, consequently, improving patient and graft survival. The population of long-term survivors after OLT is now 10-fold greater than the number of transplantations performed
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Transplantation Proceedings, 47, 233e239 (2015)
each year. In addition to prolonging survival, a substantial number of studies have found that OLT improves recipient quality of life [2e6]. Ultimately, outcomes of OLT will need to be judged not only by survival, but also by the number of quality life-years restored, a measure that incorporates both survival rate and the quality of the time survived. Among the quality of life indicators of interest to physicians and policy makers is the impact of OLT on postoperative employment. Several factors may be associated with unemployment after liver transplant surgery. About two-thirds of patients who have received a liver transplant and have done well medically, nevertheless, do not become employed after the procedure [7]. Posttransplant unemployment has been associated with poor health, disability status, early *Address correspondence to Amina Huda, NP, PhD, Division of Abdominal Transplantation, Stanford University Medical Center, 750 Welch Rd., Suite 319 e MC 5731, Palo Alto, CA 94304. E-mail: [email protected] 0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2014.10.022
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retirement, and fear of losing disability or Medicaid benefits [8,9]. Examination of factors that might influence employment status among working-age liver transplant recipients is particularly important given the economic downturn of the last few years. Unemployment has consistently surpassed 8% since mid2009 and remains more than double the rate of 10 years ago [10]. Liver transplant recipients and other individuals with chronic disease have increased risk of unemployment compared with the general population for a variety of reasons, including severity of illness, work-related factors, and available social support [11,12]. Further, >$955 billion in lost productivity annually is attributable to chronic disease states. Well-designed prevention and treatment efforts that increase employment opportunities and capacity are needed to reduce the burden of chronic diseases and alleviate their negative economic consequences [13]. One step toward the development of these efforts is a better understanding of factors that may act as potential barriers to employment. Toward this end, this article reviews and summarizes studies of posttransplantation outcomes with the aim of highlighting issues that affect transplant recipients’ employment statuses. FACTORS ASSOCIATED WITH EMPLOYMENT AFTER OLT Age
Several studies evaluated employment after OLT of those 18 years, of whom more than one-half showed significant data [8,14e18]. A study by Loinaz et al [15] provided a detailed evaluation of employment patterns of 137 patients before and after OLT at a center in Madrid, Spain. Fifty-six patients (41%) returned to work 2.6 months, on average, after transplantation. Patients <50 years old and those who had worked within 12 months pretransplantation were significantly (P ¼ .004) more likely to return to work than were patients >50 years who had been unemployed for 1 year before transplantation. In another single-center study in Canada, Adams et al [16] concluded that recipient age was related to the likelihood of returning to work. The found the mean age of employed patients was significantly younger than unemployed patients (41.7 1.2 vs 49.6 1.3 years; P ¼ .0001). Huda et al [17] examined factors that affected employment status in 21,942 OLT recipients. The study used the United Network for Organ Sharing data registry to determine the proportions of recipients who were employed and unemployed within 24 months after OLT between 2002 and 2008. Approximately one-quarter of OLT recipients (5360 [24%]) were employed within 24 months after OLT; the remaining recipients had not returned to work. The study found that patients who were >40 years old were less likely to be employed after OLT than were patients 40 years old (odds ratio [OR], 0.72; P ¼ .0001). In another single-center study from the Mayo Clinic, Rongey et al [8] examined 186 adult OLT recipients who survived for 1 year after OLT. The employment rate was higher for OLT recipients who
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were <65 years of age (61%); only 26% of those 65 years old were employed. Only 2 studies [9,19] concluded that age was not a predictor of returning to work after transplantation; however, sample sizes in those studies were small. Although the literature generally reports that younger transplant recipients are more likely to work after transplantation than are older recipients, the causal factors are complicated by the fact that older patients are more likely than younger patients to seek early retirement, rather than employment. Moreover, published studies have not identified fully the reasons why many younger, healthy transplant recipients do not return to work. For example, it is possible that younger, compared with older, transplant recipients have higher incidences of alcohol abuse and/or drug dependency, which might result in a somewhat lower employment rates if employers are reluctant to hire patients with a history of substance abuse. Further attention to employment outcomes in transplant populations, particularly in younger recipients, will be important to research. Gender
Researchers have not examined the effects of gender on post-OLT employment extensively. Cowling et al [20] studied 88 male and 61 female OLT recipients. Recipients completed a questionnaire at their pretransplant evaluation and again at their 1- and 2-year follow-up visits at Baylor University Medical Center. The study found a significantly greater percentage of men, compared with women, who reported current employment at pretransplant evaluation (P ¼ .001) and again at the 1-year after OLT (P ¼ .019). By the second year, employment rates between the sexes were similar. Gorevski et al [19] examined factors that affected depression and employment status among 91 OLT recipients. The study found that a significantly greater percentage of men, compared with women, were employed after OLT (OR, 4.1; P ¼ .04). Huda et al [17] supported these findings and found that females were 0.57 times less likely than were males to be employed after OLT (P ¼ .0001). In contrast, Hunt et al [10] study of 52 patients compared those who were employed (60%; n ¼ 31) posttransplantation to those who were not. They found no difference in gender between patients who were employed or unemployed posttransplantation. The mixed findings presented here are in part related to a definitional issue in which “work” is considered synonymous with employment. Few articles have discussed and distinguished the contributions of household workers [16,21]. For example, Adams et al [16] and Newton [21] used a definition that categorized homemakers and students as “employed” if they had returned to their same pretransplant roles. Such a definition substantially affects the results. Newton found that, after OLT, 63% of recipients were working for either pay or in one of these other roles. Using the classic definition of work as paid employment would have resulted in a return-to-work rate of 36%. Another study by Newton [22], again defining work to
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Table 1. Employment Rates by Gender
differences on employment rates at either 1 or 2 years posttransplantation. Some earlier work has found little association among samples in which >60% of the study sample was employed after OLT [9,21]. In the case of the Hunt et al [9] study, the absence of an education effect was attributed to the small sample size (52 patients). The Newton [21] study was larger (230 patients), making the finding of no education effect more difficult to ignore. Two studies in this same period found that employed patients tended to be better educated [14,20].
Author
Sample
Male
Female
Employment (%)
Adams [16] Hunt [9] Huda [17] Loinaz [15] Saab [18] Sahota [23]
203 52 21,942 137 308 105
79 34 15,474 90 181 66
124 18 6468 47 127 49
57 60 24 41 26 49
include both employment and household work, found that 59% of female alcoholic liver transplant recipients worked after OLT, including 17% who reported that they were household workers. The employment rate after OLT, as reported in published studies, is shown in Table 1.
Employment Status Before Transplantation
Racial disparities in posttransplant care and outcomes are not well studied. One reason may be racial barriers to OLT [24]. For example, in 2005, 6.8% of all patients on the liver transplant (OLT) waiting list and 9.4% of OLT recipients were African American. These rates contrast with the US population, where African Americans comprise 12.9% of the total population. Underrepresentation does not seem to be a factor for the Hispanic population. The fraction of Hispanic patients on the OLT waiting list (16%) has nearly tripled in the last decade. Hispanics constitute 13% of OLT recipients and 12.5% of the US population [25]. Another factor is that studies typically have not over sampled race/ ethnic groups to ensure adequate sample sizes. Reflective of this, only 3 studies explicitly evaluated the association between race/ethnicity and employment posttransplantation [9,17,18]. Studies conducted by Hunt et al [9] and Saab et al [18], which attempted to look at this issue, did not find a difference in race/ethnicity in terms of employment rates posttransplantation; however, their sample sizes were small. For example, the Hunt et al study included 52 patients [9]. Huda et al are an exception in the literature in their work with the United Network for Organ Sharing dataset [17], which yielded a significant race/ethnicity difference between Hispanics and whites. Hispanics were 0.58 times less likely than whites to be employed after transplantation. The cause of this difference could not be determined in the data available to these investigators.
Pretransplant employment status is a highly predictive main effect of whether patients return to work. Rongey et al [8] examined employment status among 186 long-term OLT recipients. Ninety-eight patients were employed posttransplantation. Those with employment before transplantation had substantially higher odds (5:1) of returning to work did than those without a prior work history. Huda et al [17] came to the same conclusion in a large national study (n ¼ 21,942). These authors found that patients who worked before OLT were 4.8 times more likely to be employed after transplantation than those who did not work before transplantation. This study did not have specific employment information for patients beyond the period immediately before the OLT. It is possible that patients who have been out of the workforce for long periods “unemployed” before OLT. Sahota et al [23] provided information about individuals who worked during the 5 years before OLT, and found that they were more likely to return to work than those who did not work during this interval. However, even in this study, patients who had held a job for >6 months before OLT were the most likely to return to employment. Prior occupation is another factor. Patients such as farm workers or unskilled laborers who held “low-skill” and more physically demanding jobs were less likely to return to work than were executives, administrators, managers, or technicians. The differentiation of occupation effects was also reported in earlier work by Adams et al [16]. That study found OLT recipients who worked in nonoffice jobs were significantly less likely to return to work after transplantation than were patients who held office jobs.
Education
Health Status/Functional Status
Employment after OLT has been studied regarding the impact of educational level. More recent studies tend to report that years of education attained before OLT has a significant effect on employment after transplantation [14,17,23,26]. Cowling et al [26] used a prospective design with 88 male and 61 female OLT recipients and found that more educated men (>12 years of schooling) reported higher employment rates than did their lesser educated counterparts (<12 years) at 1 and 2 years after transplantation (45% vs 19%, respectively). Among women, the findings revealed no influence of educational
Health status has been widely used when examining influences on returning to work. Adams et al [16] used the Sickness Impact Profile to study 217 patients who had undergone OLT and survived for 9 months. The researchers compared patients who were employed posttransplantation with those who were not. They found that the employed group was younger, had shorter pretransplantation disability, and had significantly lower Sickness Impact Profile scores in the areas of ambulation, home management, physical function, and pain than did those who remained unemployed. Hunt et al [9] reported that, when
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patients were queried about the most important factor preventing their return to work, 80% cited “problems with their health.” In a study of 186 liver transplant recipients, Rongey et al [8] also showed that poor health was the most common reason for unemployment. A large cohort study (n ¼ 21,942) from Huda et al [17] reported that patients with limited functional status were less likely to work after transplantation than were patients with no functional limitations. Pretransplant physical/functional status can greatly influence the ability to perform activities of daily living post transplantation. Patients with end-stage liver disease may be confined to the hospital, unable to walk short distances, or/ and inotrope dependentdall of which contribute to severe deconditioning. Although these conditions may prolong rehabilitation of the patient and, therefore, prolong the period before returning to work or preventing them from working, these attributes have not been included in measures of health status. However, a Danish study conducted by Aadahl et al [27] assessed fatigue and physical function after OLT. Their study used the 36-Item Short Form Health Survey (SF-36), Multidimensional Fatigue Inventory (MFI20), and Hospital Anxiety and Depression Scale with a sample of 130 OLT recipients. The finding revealed that Danish OLT recipients did not differ from the general population on mental health, but did differ on all physical and social health dimensions. The researchers also found that patients who were not working (n ¼ 70) had poorer physical function (SF-36 score, 64 25) and more physical fatigue (MFI-20 score, 57 34) than did patients who were either working or studying (n ¼ 60; SF-36, 90 14; MFI-20, 31 26). Saab et al [18] also used the SF-36 to study employment and quality of life of post-OLT patients (n ¼ 316). All SF-36 domains collected posttransplantation were significantly lower in the OLT cohort compared with the general population (P .001). Two domains were significantly associated with posttransplantation unemployment: physical functioning (OR, 1.17; P .01), which assesses limitations in physical activities because of health problems, and role physical (OR, 1.1; P .01), which assesses limitations in usual role activities because of physical health problems. Mental health had no association with employment (OR, 0.98; P .09). The reviewed studies found that poor post-OLT physical health and disability were associated with posttransplantation employment status. However, no study categorized the reasons for poor health. The prevalence and severity of specific symptoms and problems after OLT have not been addressed sufficiently by the generic questionnaires used in the reviewed studies. In addition, information about whether quality of life was improved by OLT is limited. Model for End-Stage Liver Disease Score
The Model for End-Stage Liver Disease (MELD) score was originally proposed as a means to predict short-term mortality in patients with end-stage liver disease. In clinical
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practice, the MELD score is often used as an overall indicator of the patient’s functional health status. Three studies found evaluated employment after OLT adjusting for preOLT MELD scores. Sahota et al [23] (n ¼ 105) investigated the correlation between posttransplant employment and clinical variables (eg, etiology of liver disease, MELD score) before and after OLT. The study found no association between the severity of clinical status before and after OLT and employment. Saab et al [18] (n ¼ 308) similarly found that MELD scores were not predictive of posttransplant employment. A large, national study [17] using the United Network for Organ Sharing date registry found the proportion of employed patients with a pretransplant MELD score of <21 was slightly higher than the proportion of patients who were not employed after transplantation. However, this relationship did not attain significance after adjustments for all other study covariates. Huda et al [17] recognized that the MELD scores of patients with hepatocellular carcinoma could be calculated based on the laboratory values alone or with the inclusion of exception status scores. They conducted a separate analysis to assess the sensitivity of the results to this classification choice. Using the laboratory-based MELD score increased the number of patients with a MELD score of <21 and decreased the number of patients with scores ranging from 22 to 31. There was little change in the number of patients with MELD scores of <31. The MELD score ORs from the models predicting post OLT employment status were similar in magnitude and were non-significant in both sets of models. Alcohol-Related Liver Diseases Versus NoneAlcohol Related Liver Diseases
A University of Michigan study (n ¼ 122) by Newton [22] examined the difference between those with alcoholrelated liver disease (ALD) and those with other causes. The sample consisted of 47 ALD women, 60 non-ALD women, 48 ALD men, and 20 non-ALD men. The study showed that female ALD recipients’ post-OLT work outcomes were similar to those of female non-ALD recipients. Moreover, female ALD recipients returned to work at rates higher than either the ALD (52%) or the non-ALD male recipients (56%). This somewhat high return to work rate among females could be owing to the inclusion of household workers within the definition of work. Ten ALD recipients (all female) who returned to work posttransplant were household workers. Some studies have found no ALD effects on post-OLT employment. Nicholas et al [28] found that history of alcohol use did not influence recipient employment after transplantation. Cowling et al [20] supported these findings in a study of 84 ALD and 68 non-ALD recipients; all had undergone OLT at a single, urban teaching hospital. The specific objective of the study was to describe and qualify liver transplant recipients’ societal reintegration after OLT. The researchers also compared the degree of societal reintegration between individuals transplanted for ALD and non-ALD liver disease. No difference between groups was
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Table 2. Employment Rates by ALD and Non-ALD Author
Sample
ALD (n)
Non-ALD (n)
Employment (%)
ALD Employment (%)
Non-ALD Employment (%)
Cowling [26] Huda [17] Newton [22] Pageaux [29]
152 21,942 122 39
84 4,497 95 22
68 17,445 80 17
36 24 55 44
33 21 59 30
38 79 62 60
Abbreviation: ALD, alcohol-related liver diseases.
noted in the proportion of subjects employed. Nearly 70% of employed individuals in both groups reported working 40 hours per week. A French study yielded very different findings [29]; 30% of ALD patients and 60% of non-ALD patients returned to employment posttransplantation. The significant difference between ALD patients and non-ALD patients seems to be related to the level of occupation before transplantation. Pre-OLT employment rates were lower among ALD patients than non-ALD patients. The poorer medical conditions of patients with ALD (81% Child-Pugh’s score C) than those with non-ALD (63% Child-Pugh’s score C) before transplantation may have also contributed to this discrepancy. Huda et al [17], using a US national transplant registry dataset, supported the French results. Their study showed that patients with non-ALD were 63% more likely than patients with ALD to work after transplantation, after adjusting for MELD scores and pre-OLT employment status. A summary of the influence of ALD on employment after OLT is shown in Table 2. The comparison of these studies suggests that slightly fewer patients with ALD than non-ALD worked at 1 year. A potentially confounding factor in these studies is that the mean age of transplant recipients with non-ALD was significantly younger than that of transplant recipients with ALD. Because no study reviewed described the nature of employment (beyond whether full time or part time), it could not be determined whether patients returned to the same or equivalent jobs. Medical Insurance
Health insurance is closely tied to employment in the United States, because most private insurance is obtained through the workplace. Fear of insurance loss may act as an incentive for individuals seeking employment. Likewise, the cost of insurance for those with histories of OLT may be a disincentive for employers asked to hire OLT recipients. A third consideration is that those with government medical insurance such as Medicaid may lose coverage if they have gainful employment with incomes above the Medicaid income qualification thresholds. Hunt et al provided support for the idea that Medicaid recipients may have an incentive to remain unemployed [9]. Patients insured by Medicaid before transplantation were 1.7 times more likely to remain unemployed after transplantation than were those with other forms of insurance. For those patients returning to work after transplantation, 19 of 31 (61%) returned to the same job.
In contrast with these findings, Rongey et al [8] examined factors that affect health insurance and employment status in 186 long-term liver transplant recipients, and found no relationship. Almost one-half of these patients (n ¼ 98) were employed posttransplant. In this sample, all but 3 individuals had health insurance of some type. This included 18% who received their insurance through their spouse, 38% reporting having >1 source of health insurance coverage, 55% with their own private insurance, and 36% with public insurance (ie, Medicare, Medicaid, Veteran’s Administration, or Native American programs). Disability Benefits
Saab et al [18] showed that the lack of disability insurance before transplantation (OR, 0.50; 95% CI, 0.24e0.10; P ¼ .05) was independently and significantly associated with posttransplantation employment. Rongey et al [8] yielded a similar finding; 12% indicated that they were able to work, but were afraid to do so for fear of losing their disability benefits. The authors did not find any association between Medicaid and unemployment. Sahota et al [23] conducted a cross-sectional study of OLT recipients to investigate the association between patients’ socioeconomic and quality-of-life parameters and employment status after transplant. The researchers noted that patients who received Social Security Disability Benefits for >6 months were less likely to return to work after transplantation. Among patients who were not working after OLT, 65% cited poor health and 20% cited loss of health insurance coverage if they returned to work as reasons for not working. The duration of disability before transplantation also influences posttransplant employment. An early study of employment after OLT from the University Hospital of Ontario, Canada found that 40% of OLT recipients were employed full time after transplantation [17]. Seventeen percent of patients were employed part time and 43% of patients were unemployed. The authors found that the duration of disability before transplantation had a significant effect on posttransplantation employment status. Only 33.6% of patients who had not worked in the 5 years before receiving their transplant returned to work, whereas 75% who had worked during this period were employed after transplant (P .0001). Similarly, the mean period of pretransplantation disability was significantly less among the employed patients compared with the unemployed patients (P .01) [16]. It seems that the longer the disability period pretransplantation, the more difficult it is for recipients to return to work post transplantation.
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Studies to date have not fully distinguished the extent to which employment rates after OLT are related to physical disabilities or the financial burdens that develop with the loss of disability benefits. Moreover, legislation has changed over the years to help patients overcome post-OLT financial burdens that may lead to more encouraging employment outcomes for the OLT population. For example, a Medicaid program, “Ticket to Work,” is designed to assist transplant patients to secure employment after surgery. In addition, Medicaid allows a buy-in program that encourages persons with a disability to work and retain their health care coverage through Medicaid. Research in countries with universal health care could provide a helpful natural experiment in separating the effects of health insurance coverage and health status on posttransplant employment. However, even in these situations, the potential confounding effect of income available through disability insurance or social programs, and the extent to which employment affects access to or loss of these benefits remains to be examined. Geography
Another variable that may influence an individual’s return to work after OLT is where someone lives. Data from some of the most representative studies performed across different regions of the United States are shown in Table 3. These studies reveal considerable variation in employment rates after OLT. Some of this variation seems to be attributable to local economic conditions that are subject to change over time. For example, a 60% employment rate after OLT was found in North Carolina, a state with a growing economy [9]. In contrast, Saab et al [18] found a 27% employment rate during a period of poor economic conditions and a high unemployment rate in the United States. Similarly, a low employment rate (36%) was reported in a Texas study [26], which was conducted during a period of high unemployment. These rates of unemployment, even in the best circumstances, contrast the prevailing unemployment rates of 4%e8% found in the United States during the late 1990s and early 2000s. Attitudes of Potential Employers
Employers’ attitudes toward transplant recipients may also be a barrier to returning to work [30,31]. One factor affecting attitudes is that employment is a common vehicle for obtaining health insurance coverage. A transplant recipient may be Table 3. Influence of Geographic Region on Employment Rates After Liver Transplantation in the United States Author
States
Sample
Employment (%)
Cowling [26] Hunt [9] Newton [21] Rongey [8] Saab [18] Sahota [23] Huda [17]
Texas North Carolina Michigan Minnesota California California All States
152 52 122 217 308 105 21,942
36 60 55 55 27 42 24
deemed too “high risk” for employment-based health insurance. The latter is especially true for businesses that lack a large pool of employees to disperse the burden of high costs associated with organ transplantation without increasing overall health insurance costs. A Mayo Clinic study on health insurance and post-OLT employment found that of 179 respondents, 10 reported that they were denied (6%) and another 6 were terminated from (3%) employment because of their transplant [8]. Similar findings were reported in a more recent post-OLT employment and quality-of-life study. Of 308 adult OLT recipients, 13 reported having been denied employment because of their transplant [18]. The reviewed studies have found employment rates among OLT recipients ranging from 22% to 60%. These rates vary widely for a number of reasons; among them is the lack of uniformity in the time from OLT and exclusion criteria used to define the study samples. Furthermore, studies on returning to work after OLT were conducted in single centers with small patient cohorts and were specific to limited time periods. Despite these limitations, a common conclusion is evident: Social rehabilitation, at least as measured after OLT, lags behind the medical results of transplantation. The combined factors of age, length of pretransplant disability, pretransplant dependence on government financial assistance, self-reported health status of not being able to work, and <6 months posttransplant seemed to be barriers that prohibited many recipients who were not medically disabled from returning to work. The majority of posttransplant employment studies were descriptive, and none were trials or evaluations of efforts designed to increase employment. Many studies on quality of life after OLT have potential biases. Commonly, they excluded the very ill or recipients considered “unemployable” by the investigators. Another limitation was the absence of a uniform sampling designs. This includes the absence of overweighting of special groups, namely race/ethnic minorities, different subgroups defined by pretransplant education and work histories, persons eligible for disability benefits and health insurance after the OLT, and inconsistency among studies concerning the pretransplant and posttransplant study periods. Also, little consistency exists in the measures used to define such basic items as employment, health status, functional limitations, education, work experience, and jobseeking behaviors. Studies also do not differentiate, either in the sample plan or outcomes, between transplant recipients who returned to the jobs they held before transplantation or those seeking other positions, between full- or part-time positions, or between full-time students and housewives as alternative statuses of employed. More rigorous, prospective studies need to be performed that examine predictors of unemployment using multivariable analyses would be recommended. Previous work has helped to identify factors associated with employment, and the measurement and sample design issues that need consideration. This work has also shown that age, college degree, pretransplant employment, and post-OLT health status are important correlates of employment. Transplant teams need to build off
EMPLOYMENT AFTER LIVER TRANSPLANTATION
of this experience and begin to formulate full social rehabilitation programs for transplant recipients. Specific interventions might be developed to change recipients’ health perceptions and include occupational counseling and job referrals. One practical issue is whether studies and interventions should be tailored separately for white collar and more physically demanding occupations. There is also a policy question of understanding how disability benefits (including income support) and health insurance operate as either incentives or disincentives for employment. The implementation of the Affordable Care Act, with the elimination of preexisting condition restrictions, may prove helpful in reducing barriers to employment. REFERENCES [1] Karam V, Castaing D, Danet C, et al. Longitudinal prospective evaluation of quality of life in adult patients before and one year after liver transplantation. Liver Transpl 2003;9:703e11. [2] Belle SH, Porayko MF, Hoofnagle JH, et al. Changes in quality of life after liver transplantation among adults. National Institute of Diabetes and Kidney Diseases (NIDDK) Liver Transplantation Database (LTD). Liver Transpl Surg 1997;3:93e104. [3] Bravata D, Olkinn I, Barnato A, et al. Health-related quality of life after liver transplantation: a metaanalysis. Liver Transpl Surg 1999;5:318e31. [4] Caccamo L, Azara V, Dogila M, et al. Longitudinal perspective measurement of the quality of life before and after liver transplantation among adults. Transplant Proc 2001;33:1880e1. [5] Gross CR, Malinchoc M, Kim WR, et al. Quality of life before and after liver transplantation for cholestatic liver disease. Hepatology 1999;29:356e64. [6] Tarter RE, Switala J, Arria A, et al. Quality of life before and after orthotopic liver transplantation. Arch Intern Med 1991;151: 1521e6. [7] Bravata D, Keeffe EB. Quality of life and employment after liver transplantation. Liver Transpl 2001;7:S119e23. [8] Rongey C, Bambha K, Vanness D, et al. Employment and health insurance in long term liver transplant recipients. Am J Transplant 2005;5:1901e8. [9] Hunt CM, Tart JS, Dowdy E, et al. Effect of orthotopic liver transplantation on employment and health status. Liver Transpl Surg 1996;2:148e53. [10] Bureau of Labor Statistics. Labor force statistics from the current population survey. U.S. Department of Labor. Available at http://data.bls.gov. Accessed April 14, 2011. [11] Varekamp I, Verbeek JH, van Dijk FJ. How can we help employees with chronic diseases to stay at work? A review of interventions aimed at job retention and based on an empowerment perspective. Int Arch Occup Envrion Health 2006;80:87e97. [12] Grammenos S. Illness, disability, and social inclusion. European Foundation for the Improvement of Living and Working Conditions; 2003. Available at, http://www.eurofound.europa.eu. Accessed April 15, 2011.
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