Occupational Capacity Following Surgical Revascularization for Lower Limb Claudication

Eur J Vasc Endovasc Surg 34, 709e713 (2007) doi:10.1016/j.ejvs.2007.06.006, available online at http://www.sciencedirect.com on

Occupational Capacity Following Surgical Revascularization for Lower Limb Claudication R.S. Vohra, P.A. Coughlin and M.J. Gough* Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK Objectives. Little is known about patient’s ability to return to work following surgical revascularization for lower limb claudication. A retrospective cohort study was performed to determine the effect of lower limb surgical revascularization on subsequent employment status. Design and methods. Patients who had undergone surgical revascularization between February 2001 and February 2005 and who were aged <65 years, were identified from a prospective database and contacted via a postal questionnaire. Results. Of 139 patients identified 19 had died. Questionnaires were returned by 80/120 patients (66.7%). Of these 8, 36 and 36 patients had undergone aortic, groin or infra-inguinal procedures respectively. Pre-operatively, 59 were employed, 17 unemployed and 4 retired. Post-operatively, 51 returned to work, 16 were unemployed, and 13 retired. Those who retired post-operatively were significantly older (p < 0.05) than the remainder. After a median hospital stay of 15 (iqr 4e45) days those returning to work did so after a further 26 (iqr 7e112) days, although this was delayed following aortic procedures (p < 0.05) and in patients with non-intermediate occupations (p < 0.05). Conclusions. Two thirds of potentially employable patients with claudication return to work following surgery including all those undergoing lower limb revascularization who were employed pre-operatively. This is influenced by age, the type of procedure and pre-operative occupation. This data can be used to predict return to work in patients requiring surgery for intermittent claudication. Ó 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Keywords: Peripheral vascular disease; Occupation.

Introduction Intermittent claudication may have a significant impact on quality of life1 and affects 3% of the working population (aged <65 years of age).2 Further, the physical incapacity associated with claudication can lead to problems with employment and reduce work capacity.3 Only a minority of claudicants proceed to surgical revascularisation4 and young patients undergoing vascular reconstruction have higher mortality and operative failure rates.5 Few studies have examined the effect of surgery on a patient’s ability to return to work.6e8 In these largely historical studies 60e90% of patients were able to returned to work at a mean of 13 weeks following lower limb revascularisation.7,8 Only 3% of patients who had not been working preoperatively were able to gain employment.8

*Corresponding author. Mr. M.J. Gough, Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK. E-mail address: [email protected]

Since these studies were published selection criteria for surgery may have changed. Further it is possible that alterations in surgical techniques and improvements of peri- and post-operative care may have influenced a claudicants ability to return to work. This study examines the impact of lower limb revascularization on subsequent employment status of patients with intermittent claudication and attempts to identify reasons for failure to return to work.

Materials and Methods Ethical approval from the local research ethics committee was obtained for this study. Patients who underwent surgical revascularization for intermittent claudication between 01/02/2001e28/02/2005 and were aged <65 years at the time of surgery were identified from a prospectively maintained vascular database. Clinical, procedural and general demographic data was collected from the database. Procedures were grouped into aortic (abdominal and

1078–5884/000709 + 05 $32.00/0 Ó 2007 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

710

R. S. Vohra et al.

retroperitoneal approaches); groin (iliofemoral endarterectomy and femoro-femoral crossover) and infrainguinal bypass (femoro-popliteal) procedures. Information relating to work status pre- and postsurgery, occupation and length of convalescence was collected using a postal questionnaire which was initially sent to patients in August 2005. If a response was not received within four weeks, a reminder letter and another questionnaire were sent. In the UK socio-economic class is determined by occupation and in this study was therefore classified according to the recently published National Statistics socio-economic classifications (NS-SEC): Class 1 e managerial and professional occupations; Class 2 e intermediate occupations (e.g. clerical and administrative professions); Class 3 e manual occupations; Unemployed (U) and Retired (R).9 Non parametric analysis was used. Values are expressed as frequencies and percentages or as median values (þ/ interquartile ranges) where appropriate. Kruskall Wallis ANOVA (KW ANOVA) test was used to determine differences between groups. Correlation was determined using Spearman Rank Correlation. Chi Squared test was used to determine differences between groups for categorical data. All analyses were performed using Analyse It (Leeds University, UK) with a p value < 0.05 deemed significant.

Results Four hundred and thirty-six patients underwent surgical revascularisation for claudication between 02/ 01/2001e28/02/2005. Of these 139 patients (31.9%) were aged <65 years at the time of surgery. Nineteen patients had died of whom 9/436 (2%) died within 30 days of surgery. The questionnaire was returned by 80/120 (66.7%). The demographics of respondents, non-respondents and those known-to-be deceased are presented in Table 1. The risk factor profile was as expected in both respondents and non-respondents, and there was no difference in procedures performed between the two groups. The deceased group has a higher incidence of diabetes mellitus, renal impairment and coronary artery disease. Table 2 shows the employment status of respondents, grouped by NS-SEC class pre-operatively. There were 9 patients in class 1, 12 in class 2, 38 in class 3, 4 were retired and 17 unemployed. Postoperatively, 16 patients were unemployed, 51 were still in active employment and 13 now described themselves as being retired. Of those who were unemployed or retired post-operatively, 13 and 4 respectively cited their continued ‘illness’ as the main reason. Eur J Vasc Endovasc Surg Vol 34, December 2007

Table 1. Baseline general demographics and surgical procedures performed Demographics

Responders (n ¼ 80)

Non-responders (n ¼ 40)

Deceased (n ¼ 19)

Age at surgery (range) Males

58 years (35e64) 57 (71.3)

57 years (40e64) 31 (77.5)

58 years (43e63) 14 (73.7)

Risk factors Smoker Diabetes Mellitus Hypertension Hyperlipidemia

50 17 53 62

24 (60) 11 (27.5) 25 (62.5) 34 (85)

12 (63.2) 11 (57.9)a,b 11 (57.9) 11 (57.9)b

11 (27.5)

9 (47.3)

(62.5) (21.3) (66.3) (77.5)

Symptomatic co-morbidity Coronary artery 22 (27.5) disease Cerebrovascular 11 (13.8) disease Renal impairment 0 (0)

3 (7.5)

2 (10.5)

2 (5)

3 (15.8)a

Procedures performed Aortic 8 (10) Groin 36 (45) Bypass 36 (45)

6 (15) 18 (45) 16 (40)

3 (15.8) 3 (15.8)a 13 (68.4)

Demographics were taken from the prospectively maintained vascular database and divided on the bases of respondents, nonrespondents and deceased patients. Values are given in numbers (%) unless stated. a p < 0.05 Chi squared test deceased patients vs. responders. b p < 0.05 deceased patients vs. non-responders.

The median length of stay was 15 (iqr 4e45) days and for those returning to work, the median time off work estimated by the patient following discharge from hospital was 26 (iqr 7e112) days. There was no correlation between age and length of stay (p ¼ 0.525 e Spearman Rank Correlation), length of stay and overall time off work (p ¼ 0.148) or age and overall time off work (p ¼ 0.113). There were no significant differences in age when considering type of surgery performed. There was no other significant difference in the types of lower limb reconstructions performed when divided by social class except only patients in social class 3 underwent aortic procedures (p ¼ 0.006 e Chi squared test). Of the patients in pre-operative employment, those in social class 2 had a significantly shorter post-operative stay (p ¼ 0.005 Kruskall Wallis Analysis) and also returned to work earlier (p ¼ 0.001 Kruskall Wallis Analysis). The convalescence times were also analysed according to the procedure performed (Table 3). There was no significant difference in either age or length of stay between the three operative groups (p ¼ 0.440 and p ¼ 0.155 respectively Kruskall Wallis Analysis). As expected patients undergoing aortic surgery had significantly longer off work compared to the other groups (p ¼ 0.035 Kruskall Wallis Analysis).

711

Occupational Capacity and Vascular Surgery

Table 2. Procedures and employment status pre- and post-operatively divided according to NS-SEC Procedures

Employment

NS-SEC

n

Age

Aortic

Groin

Lower Limb

Pre-op

Post-op

Length of stay

Time off work

1 2 3 U R

9 12 38 17 4

56 60 58 57 63

e e 8 e e

7 6 16 5 2

2 6 14 12 2

9 12 38 0 0

9 10* 30* 2 0

12 9.5 14 13 9.5

28 7 28 84 e

(53e57) (57e63) (31e67) (54e59) (63e63)

(12e17) (7e11) (12e14) (10e24) (8e12)

(28e35) (7e7) (14e58) (84e84)

Information collected from the database and questionnaire responses is presented divided by NS-SEC. Median values are given (range). * 2 and 8 patients respectively retired following surgery.

When considering post-operative employment status there was no significant difference in length of stay in patients who were unemployed (median 13 days; iqr 11.5e21), retired (median 13 days; iqr 10e19) or working (median 12 days; iqr 10e16.5) following surgery ( p ¼ 0.653 Kruskall Wallis Analysis). The patients who subsequently retired post-operatively were significantly older (median age 62 years; range 51e63 years) than those who were either unemployed (median age 58 years; range 40e64 years) or working (median age 57 years; range 35e64 years e p ¼ 0.046 Kruskall Wallis Analysis). Two patients who underwent femoro-popliteal bypass and were previously unemployed returned to work post-operatively. Of the 13 patients who had symptomatic coronary artery disease and were working pre-operatively, 10 returned to work compared to the 41 of the 46 patients without symptomatic coronary artery disease.

Discussion When claudication has a significant impact on quality of life, intervention maybe required. There are a limited number of studies assessing employment status after vascular surgery and these were published 20e 30 years ago. Our results confirm that >60% of patients return to work following surgical treatment of claudication and abdominal surgery is associated with a longer convalescence than other types of surgery. Finally, only a minority of unemployed patients return to work within three months of discharge following a successful operation. This study also shows that the length of hospital stay and time off work

are linked to pre- and post-operative occupational status. Further, the time taken to return to work has reduced from a mean of 13 weeks7 to 4 weeks over the last 20 years presumably through improved pre-, peri- and post-operative care. The association of risk factors and symptomatic co-morbidities and mortality in patients undergoing revascularization confirms previous observations,10 but the presence of symptomatic coronary artery disease would not appear to disadvantage a return to work. Paid employment has been used in the Nottingham Health Profile as part of the assessment of quality of life.11 Using the Nottingham Health Profile, Klevsgard et al. reported a positive effect of revascularisation on quality of life scores in both claudicants and patients with critical limb ischaemia.12 However the median age of this cohort was above the United Kingdom retirement age (68 years) which limited the effect of using paid employment as an index of quality of life. Occupational capacity and return to work have been extensively studied in other atherosclerotic cohorts including coronary artery disease13,14 and has been used as an indicator of success following coronary artery surgery,13,15,16 where two thirds of patients resumed employment. Nevertheless there are some difficulties in using this as an outcome measure. In particular the median age of our patients at the time of surgery was 58 years. In some occupations older people are less attractive to employ due to reduced productivity when compared to the time taken to train new employees to appropriate skill levels. This is likely to mean that older patients either remain out of work for longer than younger patients or are unable to obtain gainful employment and

Table 3. Employment status pre- and post-operatively according to performed procedures Procedures

n

Age

Pre-op employment

Post-op employment

Length of hospital stay

Time off work

Aortic Groin Lower Limb

8 36 36

59.5 (48e63) 59.5 (35e63) 61.25 (40e64)

8 29 22

4 23 22

14 (11.75e20) 12 (9e15.25) 13.5 (10e21.25)

77 (68.25e84) 28 (10.5e35) 14 (7e52.75)

Information collected from the database and questionnaire responses is divided by type of procedure performed. Median values are given (range). Eur J Vasc Endovasc Surg Vol 34, December 2007

712

R. S. Vohra et al.

subsequently choose early retirement. Furthermore, early retirement may be sought by patients as a means of recovering from illness or enjoying their restored health. This may have influenced the proportion of patients who remained unemployed or retired in this study. In patients who returned to work post-operatively, those in intermediate occupations (for example clerical, administrative and sales) did so more quickly than those in manual or professional occupations. Furthermore, in other surgical procedures, including laparoscopic cholecystectomy and groin hernia repairs, physically demanding employment are again associated with longer convalescence times.17,18 Other data shows that self-employed patients returned to work earlier. The lack of employer information is a limitation of both our study and the National Statistics socio-economic classification. The protracted median length of hospital stay in this cohort was unexpected. It would be reasonable to assume that this would be shorter and linked to the type of surgical procedure as previously found in older cohorts undergoing surgical revascularisation.19,20 However this difference maybe linked in part to higher risk factor profiles and country-specific differences in our study group compared to these previous reports. Specific information on post-operative complications was not easily available. Questionnaire-based studies are limited by recall bias and the response rate. However, although there may be an element of bias, the response rate was relatively high and there was no difference in general demographics between the respondents and nonrespondents. A period of six months was left between the last operated patient included in this study and the questionnaire being sent. This allowed adequate convalescence time and is supported by the observation that all patients who returned to work in this study did so within three months. Another important factor not examined by this study is the effect of endovascular treatment on return to work. With significantly reduced hospital stay and procedural morbidity and mortality,20 this may have a great impact on return to normal life and return to work. However it is unclear if the increased availability and use of percutaneous transluminal angioplasty has influenced the number of surgical revascularizations performed.21 In conclusion two thirds of employable patients with claudication return to work following surgical revascularisation. Factors independent of occupational type and return to work are age, type of procedure and length of hospital stay. However, the type of procedure and the class of employment influence the Eur J Vasc Endovasc Surg Vol 34, December 2007

convalescence time. The data presented here can be used to predict return to work of patients undergoing surgical revascularisation and aid in the consenting process. Acknowledgements This work was supported by the Leeds Vascular Surgical Fund. No conflicts of interest to declare.

References 1 HICKEN GJ, LOSSING AG, AMELI M. Assessment of generic healthrelated quality of life in patients with intermittent claudication. Eur J Vasc Endovasc Surg 2000;20(4):336e341. 2 www.heartstats.org/ 3 VALENTINE RJ, MACGILLIVRAY DC, DENOBILE JW, SNYDER DA, RICH NM. Intermittent claudication caused by atherosclerosis in patients aged forty years and younger. Surgery 1990;107(5): 560e565. 4 DORMANDY J, HEECK L, VIG S. Lower-extremity arteriosclerosis as a reflection of a systemic process: implications for concomitant coronary and carotid disease. Semin Vasc Surg 1999;12(2): 118e122. 5 VAN GOOR H, BOONTJE AH. Results of vascular reconstructions for atherosclerotic arterial occlusive disease of the lower limbs in young adults. Eur J Vasc Endovasc Surg 1995;10(3):323e326. 6 WATERS KJ, PROUD G, CHAMBERLAIN J. Return to work after aortofemoral bypass surgery. Br Med J 1977;2(6086):556. 7 GEDEON A, BARRET A, COMBELLES JL. Return to work after reconstructive arterial surgery. J Mal Vasc 1980;5(1):47e49. 8 GLICKMAN MH, HURWITZ RL, KIMMINS SA, EVANS WE. Employment following peripheral vascular surgery: an increasingly critical issue. Surgery 1983;93:50e53. 9 Office for National Statistics. The National Statistics Socioeconomic Classification. Basingstoke: Palgrave Macmillan; 2005. 10 L’ITALIEN GJ, CAMBRIA RP, CUTLER BS, LEPPO JA, PAUL SD, BREWSTER DC et al. Comparative early and late cardiac morbidity among patients requiring different vascular surgery procedures. J Vasc Surg 1995;21(6):935e944. 11 HUNT SM, MCKENNA SP, MCEWEN J, BACKETT EM, WILLIAMS J, PAPP E. A quantitative approach to perceived health status: a validation study. J Epidemiol Community Health 1980;34(4):281e286. 12 KLEVSGARD R, HALLBERG IR, RISBERG B, THOMSEN MB. The effects of successful intervention on quality of life in patients with varying degrees of lower-limb ischaemia. Eur J Vasc Endovasc Surg 2000; 19(3):238e245. 13 OBERMAN A, FINKLEA JF. Return to work after coronary artery bypass grafting. Ann Thorac Surg 1982;34(4):353e355. 14 POCOCK SJ, HENDERSON RA, SEED P, TREASURE T, HAMPTON JR. Quality of life, employment status, and anginal symptoms after coronary angioplasty or bypass surgery. 3-year follow-up in the Randomized Intervention Treatment of Angina (RITA) Trial. Circulation 1996;94(2):135e142. 15 ALMEIDA D, BRADFORD JM, WENGER NK, KING SB, HURST JW. Return to work after coronary bypass surgery. Circulation 1983;68(3 Pt 2): II205eII213. 16 SELLIER P, VARAILLAC P, CHATELLIER G, D’AGROSA-BOITEUX MC, DOUARD H, DUBOIS C et al. Factors influencing return to work at one year after coronary bypass graft surgery: results of the PERISCOP study. Eur J Cardiovasc Prev Rehabil 2003;10(6):469e475. 17 MCLAUCHLAN GJ, MACINTYRE IM. Return to work after laparoscopic cholecystectomy. Br J Surg 1995;82(2):239e241. 18 JONES KR, BURNEY RE, PETERSON M, CHRISTY B. Return to work after inguinal hernia repair. Surgery 2001;129(2):128e135. 19 JANSEN RM, DE VRIES SO, CULLEN KA, DONALDSON MC, HUNINK MG. Cost-identification analysis of revascularization

Occupational Capacity and Vascular Surgery

procedures on patients with peripheral arterial occlusive disease. J Vasc Surg 1998;28(4):617e623. 20 ROSENTHAL D, AROUS EJ, FRIEDMAN SG, INGEGNO MD, JOHNSON BL, KRAISS LW et al. Endovascular-assisted versus conventional in situ saphenous vein bypass grafting: cumulative patency, limb salvage, and cost results in a 39-month multicenter study. J Vasc Surg 2000;31(1 Pt 1):60e68.

713

21 PELL JP, WHYMAN MR, FOWKES FG, GILLESPIE I, RUCKLEY CV. Trends in vascular surgery since the introduction of percutaneous transluminal angioplasty. Br J Surg 1994;81(6):832e835. Accepted 3 June 2007 Available online 3 August 2007

Eur J Vasc Endovasc Surg Vol 34, December 2007