- Email: [email protected]
Quality of life and employment after liver transplantation
Quality of Life and Employment After Liver Transplantation Dena M. Bravata*† and Emmet B. Keeffe‡ Key Points 1. In general, the health-related quality of life (QOL) of transplant recipients is impaired before and improves after liver transplantation. 2. Transplant recipients report largest gains in those aspects of QOL most affected by physical health and smaller improvements in areas affected by psychological functioning. 3. No utility-based measures have been used with liver transplant recipients; therefore, the necessary QOL weights for use in cost-effectiveness evaluations of liver transplantation are lacking. 4. Pretransplantation, the percentage of candidates with alcoholic liver disease (ALD) who work is less than that of candidates without ALD. However, there is no difference in rates of employment posttransplantation. 5. No study has described types of wages and benefits associated with jobs before or after transplantation or the extent to which health insurance benefits associated with employment motivate changes in work status. 6. Many studies in this field used nonvalidated heterogeneous instruments to measure QOL and employment, thus limiting the opportunity to combine results across studies and compare outcomes for liver transplant recipients with other patient populations. (Liver Transpl 2001; 7:S119-S123.)
C
hronic liver disease and its complications are the ninth leading cause of death in the United States. In addition to its effect on mortality, end-stage liver disease has a profoundly negative impact on functional status outcomes. Patients with liver failure experience various degrees of hepatic encephalopathy, with reduced cognitive function as a result of toxic metabolites that are not cleared by the failing liver and cross the blood-brain barrier.1 Other clinical manifestations of patients with hepatic encephalopathy include lability of affect, atypical emotional responses, depression, and anxiety.2 Given that this psychological and intellectual deterioration occurs concomitantly with the physical deterioration associated with liver failure, it is not surprising that patients with end-stage liver disease should have significant impairment of quality of life (QOL), often associated with loss of employment. Liver transplantation is widely accepted as treatment for end-stage liver disease. Currently, more than 85% of adult liver transplant recipients survive the first year after transplantation, and 55% survive more than 9 years.3 As clinical outcomes of liver transplantation improve, outcomes relating to transplant recipients’
overall functional status and QOL become increasingly important targets for evaluation. We recently performed a comprehensive meta-analysis of patients’ QOL and employment after liver transplantation from 89 studies that reported on 6,306 patients.4-6 We sought to characterize the overall effect of liver transplantation on various aspects of QOL and describe long-term patterns of employment. Since the publication of this work, several important studies have been published on this topic. In this report, we describe primary results of the meta-analysis and discuss contributions of recent articles in this field.
QOL After Liver Transplantation Health-related QOL is a multidimensional construct reflecting an individual’s global physical and psychosocial well-being. It is generally considered to include six principal domains: physical health, psychological health, social functioning, sexual functioning, ability to perform daily activities, and general well-being.7 Transplant recipients’ assessments of their own QOL often reflect their degree of adaptation to posttransplantation life. There are three principal methods for measuring QOL. Two methods use generic instruments for the general population, utility measures and generic health profiles, and the other method uses disease-specific instruments for patients with particular diseases. Health profiles (also called psychometric instruments) and utility-based measures of QOL elicit related, yet different, information. Health profiles measure a patient’s functional status in a given health state, and utility-based approaches assess how a patient values that From the *Department of Medicine, Center for Primary Care and Outcomes Research, and ‡Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford; and the †Department of Veterans Affairs Health Care System, Palo Alto, CA. Address reprint requests to Emmet B. Keeffe, MD, Stanford University Medical Center, 750 Welch Rd, Ste 210, Palo Alto, CA 943041509. Telephone: 650-498-5691; FAX: 650-498-5692; E-mail: [email protected] Copyright © 2001 by the American Association for the Study of Liver Diseases 1527-6465/01/0711-1008$35.00/0 doi:10.1053/jlts.2001.28520
Liver Transplantation, Vol 7, No 11, Suppl 1 (November), 2001: pp S119-S123
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health state. Utility measures are derived from economic and decision theories. They yield an expected utility score on a scale from 0 to 1 that is the primary means of including QOL in cost-effectiveness analyses. It is highly likely that liver transplant recipients who have similar levels of function will vary widely with respect to how they value different aspects of QOL. Utility-based measures would be sensitive to these differences in preferences that are not evaluated by psychometric measures. Almost all studies of QOL of patients before and after liver transplantation have used such generic health profiles as the Medical Outcomes Survey Short Form (SF-36), Karnofsky Performance Scale, Nottingham Health Profile, and Sickness Impact Profile.4 However, there are no published utility-based evaluations of liver transplant recipients. Increasingly, disease-specific health profiles for use among English-speaking liver transplant candidates and recipients are being developed and evaluated. The QOL Index–Liver Transplant Version, which measures subjectively perceived QOL, has been shown to be both reliable and valid.8 The Liver Transplant Database QOL Questionnaire was developed from standardized instruments selected to represent measures of disease, psychological status, personal function, social and role function, and general health perception.9 Although each item was taken directly from a well-validated measure, the Liver Transplant Database QOL Questionnaire has not been specifically assessed for either reliability or validity. Most recently, the Liver Disease QOL Instrument was developed for use among all adults with chronic liver disease, including those before and after liver transplantation.10 It includes the complete SF-36, in addition to 12 scales including items that evaluate liver disease–related symptoms and the self-perceived stigma of liver disease. This instrument has been tested for reliability and validity and represents a valuable addition to the armamentarium of diseasespecific scales. In general, studies of QOL of liver transplant recipients have shown that QOL of liver transplant candidates is significantly impaired and improves posttransplantation. Transplant recipients reported large gains in those aspects of QOL most affected by physical health and smaller improvements in areas affected by psychological functioning. In addition, there is no consistently shown difference in QOL of recipients drinking alcohol post-transplantation compared with those who abstain from alcohol.11,12 Figure 1 shows an overview of QOL studies included in our recently published meta-analysis.4 In this figure, black bars represent the number of
Figure 1. Proportion of positive versus nonpositive QOL studies.
studies that reported a positive result (defined as a statistically significant improvement in a QOL domain after transplantation). White bars represent the number of studies that reported a nonpositive result (defined as a statistically insignificant improvement or statistically significant worsening). For any given domain, equal numbers of positive and nonpositive studies would indicate that transplantation had no effect on that QOL domain. By comparing the observed proportion of positive studies with the binomial distribution, we obtained a level of significance for each QOL domain. This sign test provides an indication of the direction (positive or negative) of the effect of transplantation on that QOL domain, but is limited in that it neither estimates the magnitude of the effect nor incorporates sample size. Since the publication of our meta-analysis, several additional articles have reported QOL results for liver transplant recipients. Younossi et al13 presented generic (SF-36) and liver disease–specific (Chronic Liver Disease Questionnaire) QOL data for 37 patients from the Cleveland Clinic. In contrast to summary results in our analysis, these patients reported significant improvements in questions related to mental health. It is difficult to know whether the transplant recipients included in our meta-analysis failed to improve or the measurement instruments were insensitive to small but clinically significant changes. Interestingly, Younossi et al13 found that improvements in QOL were associated with less health resource use. This was particularly true for improvements in fatigue and vitality domains.
Employment After Liver Transplantation Given that the average age of adult liver transplant recipients is 45 years, a time in their lives when many expect to spend a significant portion of the day engaged
QOL and Employment After OLT
in work-related activities, employment concerns influence the QOL of patients with end-stage liver disease and liver transplant recipients. A recent study by Marchesini et al14 of 544 patients with end-stage liver disease confirmed that patients reported paid employment to be significantly affected by their health problems, particularly among men and those aged younger than 45 years. Studies of employment patterns of transplant recipients included in our meta-analysis yielded several findings.5 In Figure 2, employment results of studies that directly compared employment patterns of transplant recipients with alcoholic liver disease (ALD) with those without ALD are shown. Pretransplantation, the percentage of candidates who were employed was less among those who had ALD than among those who had liver disease not caused by alcohol (29% v 59%; odds ratio, 1.57; 95% confidence interval, 1.05 to 2.35). Posttransplantation, rates of employment between these two groups of recipients did not appear to differ, although the evidence is not definitive. Only six studies have compared employment rates for the two groups at 1-year posttransplantation, and only one study evaluated employment after the first year.
S121
A study by Loinaz et al15 published since our metaanalysis provides a detailed evaluation of employment patterns of 137 patients before and after transplantation at a center in Madrid, Spain. Primary results are listed in Table 1. When they became ill, 63 of the Spanish patients (47%) continued to work; however, only 37 patients (28%) were still working when they underwent transplantation. Those who stopped working did so an average of 1 year before transplantation. Thirty-two patients (37%) retired because of their liver disease, 2 patients (2%) retired because of their age, and 6 patients (7%) had anticipated retirement for labor problems, the nature of which were not specified. Thirteen patients changed jobs when they became sick. Work-derived income remained the same for 51% of the patients, but decreased for 49%. After transplantation, 56 patients (41%) returned to work an average of 2.6 months later. Patients aged younger than 50 years and those who had worked within 12 months pretransplantation were significantly more likely to return to work than patients aged older than 50 years or who had been unemployed for a year before transplantation. It can be very difficult to interpret results of studies presenting employment data for liver transplant recip-
Figure 2. Summary odds ratios for employment of transplant recipients with versus without ALD. An odds ratio greater than 1 indicates that transplant recipients without ALD are more likely to be employed than transplant recipients with ALD. If the confidence interval around the odds ratio overlaps 1, there is no significant difference between transplant recipients with and without ALD. P > .05 for Q statistic indicates homogeneity.
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Table 1. Employment Patterns Before and After Liver Transplantation Employment
Before becoming ill When they became ill After transplantation
Housework
Occasional
Part-Time
Full-Time
5/137 (4)
12/137 (9) See text 10/137 (7)
115/137 (87)
8/137 (6)
38/137 (28)
Performed Independently
Performed With Part-Time Help
Performed With Full-Time Help
98/137 (72) 10/32 (31) 12/28 (43)
30/137 (22) 21/32 (66) (43)
9/137 (6.3) 1/32 (3) (13)
NOTE. Values expressed as no. of patients/total no. (percent). Data in table calculated from results of the study of Loinaz et al.15
ients. This is primarily because the published studies used different definitions of part-time employment, full-time employment, and homemaking. In addition, they did not report the proportions of transplant recipients who returned to the jobs they held before transplantation or took jobs with equivalent wages and benefits or the extent to which insurance factors may have motivated some transplant recipients to return to work and others to remain unemployed or underemployed. Most studies of transplant candidates’ and recipients’ employment status used self-developed questions about employment or questions from QOL scales. For more comprehensive measurement of work practices, future studies should include questions from the Current Population Survey or the Health and Retirement Study. These are the best validated, most widely used tools for assessing the employment status of a population, antecedents and consequences of retirement, and relationships among health, income, and wealth over time, all important aspects of employment that remain poorly characterized among liver transplant recipients.16,17
Summary In this era of increasing emphasis on the cost-effectiveness of care and interventions that prolong not just length of life, but also QOL, evaluation of functional status outcomes after such a highly resource-intensive procedure as liver transplantation is critical. Increasingly, rigorous evaluations of QOL and employment before and after liver transplantation are providing a more comprehensive description of the impact of this technology on patients’ lives. The primary difficulty in synthesizing and generalizing the results of these studies derives from the heterogeneity of measurement instruments used to evaluate these outcomes. It is critical for the community of transplant physicians to use validated generic and diseasespecific QOL instruments, utility-based measures of QOL, and established employment classifications. For
example, because utility-based measures have not been used with liver transplant recipients, the necessary quality weights for use in cost-effectiveness evaluations of liver transplantation are lacking. Despite these limitations, there is a clear consensus in the current literature that as the severity of patients’ end-stage liver disease increases, their QOL and ability to remain employed decreases. In addition, as they recover from their liver transplantation procedures, many patients report significant improvements in QOL, and some are able to return to work. Interestingly, despite differences in culture and race/ethnicity that would be expected to influence work patterns and perceptions of QOL, these findings have been found among transplant recipients from Japan,18 Taiwan,19 Sweden,20 and the United States.4,5 Further research that provides detailed descriptions of the groups of patients for whom QOL is not improved and return to satisfying employment is not possible is needed. Additionally, studies of the influence of healthcare providers and social support interventions on transplant recipients’ QOL should be conducted to design posttransplantation programs that maximize favorable outcomes for transplant recipients.
References 1. Surman OS, Dienstag JL, Cosimi AB, Chauncey S, Russell PS. Psychosomatic aspects of liver transplantation. Psychother Psychosom 1987;48:26-31. 2. Surman OS. Psychiatric aspects of liver transplantation. Psychosomatics 1994;35:297-307. 3. Seaberg EC, Belle SH, Beringer KC, Schivins JL, Detre KM. Long-term patient and retransplantation-free survival by selected recipient and donor characteristics: An update from the PittUNOS liver transplant registry. In: Cecka JM, Terasaki PI (eds). Clinical transplants 1997. Los Angeles, CA: UCLA Tissue Typing Laboratory, 1998:15-28. 4. Bravata DM, Olkin I, Barnato AE, Keeffe EB, Owens DK. Health-related quality of life after liver transplantation: A metaanalysis. Liver Transpl Surg 1999;5:318-331. 5. Bravata DM, Olkin I, Barnato AE, Keeffe EB, Owens DK.
QOL and Employment After OLT
6.
7. 8. 9.
10.
11.
12.
Employment and alcohol use after liver transplantation for alcoholic and nonalcoholic liver disease: A systematic review. Liver Transpl 2001;7:191-203. Bravata DM, Keeffe EB, Owens DK. Quality of life, employment and alcohol consumption after liver transplantation. Curr Opin Organ Transplant 2001;6:130-141. McDowell I, Newell C. Measuring health: A guide to rating scales and questionnaires, vol 1 (ed 2). New York: Oxford, 1996. Hicks FD, Larson JL, Ferrans CE. Quality of life after liver transplant. Res Nurs Health 1992;15:111-119. Belle SH, Porayko MK, Hoofnagle JH, Lake JR, Zetterman RK. Changes in quality of life after liver transplantation among adults. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database (LTD). Liver Transpl Surg 1997;3:93-104. Gralnek IM, Hays RD, Kilbourne A, Rosen HR, Keeffe EB, Artinian L, et al. Development and evaluation of the Liver Disease Quality of Life Instrument in persons with advanced, chronic liver disease—The LDQOL 1.0. Am J Gastroenterol 2000;95:3552-3565. Pereira SP, Howard LM, Muiesan P, Rela M, Heaton N, Williams R. Quality of life after liver transplantation for alcoholic liver disease. Liver Transpl 2000;6:762-768. Mejias D, Ramirez P, Rios A, Munitiz V, Hernandez Q, Bueno F, et al. Recurrence of alcoholism and quality of life in patients
13.
14.
15.
16.
17. 18.
19.
20.
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with alcoholic cirrhosis following liver transplantation. Transplant Proc 1999;31:2472-2474. Younossi ZM, McCormick M, Price LL, Boparai N, Farquhar L, Herderson JM, Guyatt G. Impact of liver transplantation on health-related quality of life. Liver Transpl 2000;6:779-783. Marchesini G, Bianchi G, Amodio P, Salerno F, Merli M, Panella C, et al. Factors associated with poor health-related quality of life of patients with cirrhosis. Gastroenterology 2001;120: 170-178. Loinaz C, Clemares M, Marque´s E, Pasiero G, Gomez R, Gonzales-Pinto I, et al. Labor status of 137 patients with liver transplantation. Transplant Proc 1999;31:2470-2471. Bureau of Labor Statistics. The current population survey. Available at: http://stats.bls.gov/opub/hom/homch1%5Fa.htm. Accessed: June 12, 2001. Health and retirement study. Available at: http://www. umich.edu/⬃hrswww/. Accessed: June 12, 2001. Kita Y, Umeshita K, Gotoh M, Sakon M, Monden M, Ichida T, Ota K. Quality of life in adult Japanese patients undergoing liver transplants overseas. Transplant Proc 1996;28:1934-1936. Shih F, Hu R, Ho M, Lin HY, Lin MH, Lee PH. Changes in health-related quality of life and working competence before and after liver transplantation. Transplant Proc 2000;32:2144-2148. Hellgren A, Berglund B, Gunnarsson U, Hansson K, Norberg U, Backman L. Health-related quality of life after liver transplantation. Liver Transpl Surg 1998;4:215-221.
C
hronic liver disease and its complications are the ninth leading cause of death in the United States. In addition to its effect on mortality, end-stage liver disease has a profoundly negative impact on functional status outcomes. Patients with liver failure experience various degrees of hepatic encephalopathy, with reduced cognitive function as a result of toxic metabolites that are not cleared by the failing liver and cross the blood-brain barrier.1 Other clinical manifestations of patients with hepatic encephalopathy include lability of affect, atypical emotional responses, depression, and anxiety.2 Given that this psychological and intellectual deterioration occurs concomitantly with the physical deterioration associated with liver failure, it is not surprising that patients with end-stage liver disease should have significant impairment of quality of life (QOL), often associated with loss of employment. Liver transplantation is widely accepted as treatment for end-stage liver disease. Currently, more than 85% of adult liver transplant recipients survive the first year after transplantation, and 55% survive more than 9 years.3 As clinical outcomes of liver transplantation improve, outcomes relating to transplant recipients’
overall functional status and QOL become increasingly important targets for evaluation. We recently performed a comprehensive meta-analysis of patients’ QOL and employment after liver transplantation from 89 studies that reported on 6,306 patients.4-6 We sought to characterize the overall effect of liver transplantation on various aspects of QOL and describe long-term patterns of employment. Since the publication of this work, several important studies have been published on this topic. In this report, we describe primary results of the meta-analysis and discuss contributions of recent articles in this field.
QOL After Liver Transplantation Health-related QOL is a multidimensional construct reflecting an individual’s global physical and psychosocial well-being. It is generally considered to include six principal domains: physical health, psychological health, social functioning, sexual functioning, ability to perform daily activities, and general well-being.7 Transplant recipients’ assessments of their own QOL often reflect their degree of adaptation to posttransplantation life. There are three principal methods for measuring QOL. Two methods use generic instruments for the general population, utility measures and generic health profiles, and the other method uses disease-specific instruments for patients with particular diseases. Health profiles (also called psychometric instruments) and utility-based measures of QOL elicit related, yet different, information. Health profiles measure a patient’s functional status in a given health state, and utility-based approaches assess how a patient values that From the *Department of Medicine, Center for Primary Care and Outcomes Research, and ‡Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford; and the †Department of Veterans Affairs Health Care System, Palo Alto, CA. Address reprint requests to Emmet B. Keeffe, MD, Stanford University Medical Center, 750 Welch Rd, Ste 210, Palo Alto, CA 943041509. Telephone: 650-498-5691; FAX: 650-498-5692; E-mail: [email protected] Copyright © 2001 by the American Association for the Study of Liver Diseases 1527-6465/01/0711-1008$35.00/0 doi:10.1053/jlts.2001.28520
Liver Transplantation, Vol 7, No 11, Suppl 1 (November), 2001: pp S119-S123
S119
S120
Bravata and Keeffe
health state. Utility measures are derived from economic and decision theories. They yield an expected utility score on a scale from 0 to 1 that is the primary means of including QOL in cost-effectiveness analyses. It is highly likely that liver transplant recipients who have similar levels of function will vary widely with respect to how they value different aspects of QOL. Utility-based measures would be sensitive to these differences in preferences that are not evaluated by psychometric measures. Almost all studies of QOL of patients before and after liver transplantation have used such generic health profiles as the Medical Outcomes Survey Short Form (SF-36), Karnofsky Performance Scale, Nottingham Health Profile, and Sickness Impact Profile.4 However, there are no published utility-based evaluations of liver transplant recipients. Increasingly, disease-specific health profiles for use among English-speaking liver transplant candidates and recipients are being developed and evaluated. The QOL Index–Liver Transplant Version, which measures subjectively perceived QOL, has been shown to be both reliable and valid.8 The Liver Transplant Database QOL Questionnaire was developed from standardized instruments selected to represent measures of disease, psychological status, personal function, social and role function, and general health perception.9 Although each item was taken directly from a well-validated measure, the Liver Transplant Database QOL Questionnaire has not been specifically assessed for either reliability or validity. Most recently, the Liver Disease QOL Instrument was developed for use among all adults with chronic liver disease, including those before and after liver transplantation.10 It includes the complete SF-36, in addition to 12 scales including items that evaluate liver disease–related symptoms and the self-perceived stigma of liver disease. This instrument has been tested for reliability and validity and represents a valuable addition to the armamentarium of diseasespecific scales. In general, studies of QOL of liver transplant recipients have shown that QOL of liver transplant candidates is significantly impaired and improves posttransplantation. Transplant recipients reported large gains in those aspects of QOL most affected by physical health and smaller improvements in areas affected by psychological functioning. In addition, there is no consistently shown difference in QOL of recipients drinking alcohol post-transplantation compared with those who abstain from alcohol.11,12 Figure 1 shows an overview of QOL studies included in our recently published meta-analysis.4 In this figure, black bars represent the number of
Figure 1. Proportion of positive versus nonpositive QOL studies.
studies that reported a positive result (defined as a statistically significant improvement in a QOL domain after transplantation). White bars represent the number of studies that reported a nonpositive result (defined as a statistically insignificant improvement or statistically significant worsening). For any given domain, equal numbers of positive and nonpositive studies would indicate that transplantation had no effect on that QOL domain. By comparing the observed proportion of positive studies with the binomial distribution, we obtained a level of significance for each QOL domain. This sign test provides an indication of the direction (positive or negative) of the effect of transplantation on that QOL domain, but is limited in that it neither estimates the magnitude of the effect nor incorporates sample size. Since the publication of our meta-analysis, several additional articles have reported QOL results for liver transplant recipients. Younossi et al13 presented generic (SF-36) and liver disease–specific (Chronic Liver Disease Questionnaire) QOL data for 37 patients from the Cleveland Clinic. In contrast to summary results in our analysis, these patients reported significant improvements in questions related to mental health. It is difficult to know whether the transplant recipients included in our meta-analysis failed to improve or the measurement instruments were insensitive to small but clinically significant changes. Interestingly, Younossi et al13 found that improvements in QOL were associated with less health resource use. This was particularly true for improvements in fatigue and vitality domains.
Employment After Liver Transplantation Given that the average age of adult liver transplant recipients is 45 years, a time in their lives when many expect to spend a significant portion of the day engaged
QOL and Employment After OLT
in work-related activities, employment concerns influence the QOL of patients with end-stage liver disease and liver transplant recipients. A recent study by Marchesini et al14 of 544 patients with end-stage liver disease confirmed that patients reported paid employment to be significantly affected by their health problems, particularly among men and those aged younger than 45 years. Studies of employment patterns of transplant recipients included in our meta-analysis yielded several findings.5 In Figure 2, employment results of studies that directly compared employment patterns of transplant recipients with alcoholic liver disease (ALD) with those without ALD are shown. Pretransplantation, the percentage of candidates who were employed was less among those who had ALD than among those who had liver disease not caused by alcohol (29% v 59%; odds ratio, 1.57; 95% confidence interval, 1.05 to 2.35). Posttransplantation, rates of employment between these two groups of recipients did not appear to differ, although the evidence is not definitive. Only six studies have compared employment rates for the two groups at 1-year posttransplantation, and only one study evaluated employment after the first year.
S121
A study by Loinaz et al15 published since our metaanalysis provides a detailed evaluation of employment patterns of 137 patients before and after transplantation at a center in Madrid, Spain. Primary results are listed in Table 1. When they became ill, 63 of the Spanish patients (47%) continued to work; however, only 37 patients (28%) were still working when they underwent transplantation. Those who stopped working did so an average of 1 year before transplantation. Thirty-two patients (37%) retired because of their liver disease, 2 patients (2%) retired because of their age, and 6 patients (7%) had anticipated retirement for labor problems, the nature of which were not specified. Thirteen patients changed jobs when they became sick. Work-derived income remained the same for 51% of the patients, but decreased for 49%. After transplantation, 56 patients (41%) returned to work an average of 2.6 months later. Patients aged younger than 50 years and those who had worked within 12 months pretransplantation were significantly more likely to return to work than patients aged older than 50 years or who had been unemployed for a year before transplantation. It can be very difficult to interpret results of studies presenting employment data for liver transplant recip-
Figure 2. Summary odds ratios for employment of transplant recipients with versus without ALD. An odds ratio greater than 1 indicates that transplant recipients without ALD are more likely to be employed than transplant recipients with ALD. If the confidence interval around the odds ratio overlaps 1, there is no significant difference between transplant recipients with and without ALD. P > .05 for Q statistic indicates homogeneity.
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Table 1. Employment Patterns Before and After Liver Transplantation Employment
Before becoming ill When they became ill After transplantation
Housework
Occasional
Part-Time
Full-Time
5/137 (4)
12/137 (9) See text 10/137 (7)
115/137 (87)
8/137 (6)
38/137 (28)
Performed Independently
Performed With Part-Time Help
Performed With Full-Time Help
98/137 (72) 10/32 (31) 12/28 (43)
30/137 (22) 21/32 (66) (43)
9/137 (6.3) 1/32 (3) (13)
NOTE. Values expressed as no. of patients/total no. (percent). Data in table calculated from results of the study of Loinaz et al.15
ients. This is primarily because the published studies used different definitions of part-time employment, full-time employment, and homemaking. In addition, they did not report the proportions of transplant recipients who returned to the jobs they held before transplantation or took jobs with equivalent wages and benefits or the extent to which insurance factors may have motivated some transplant recipients to return to work and others to remain unemployed or underemployed. Most studies of transplant candidates’ and recipients’ employment status used self-developed questions about employment or questions from QOL scales. For more comprehensive measurement of work practices, future studies should include questions from the Current Population Survey or the Health and Retirement Study. These are the best validated, most widely used tools for assessing the employment status of a population, antecedents and consequences of retirement, and relationships among health, income, and wealth over time, all important aspects of employment that remain poorly characterized among liver transplant recipients.16,17
Summary In this era of increasing emphasis on the cost-effectiveness of care and interventions that prolong not just length of life, but also QOL, evaluation of functional status outcomes after such a highly resource-intensive procedure as liver transplantation is critical. Increasingly, rigorous evaluations of QOL and employment before and after liver transplantation are providing a more comprehensive description of the impact of this technology on patients’ lives. The primary difficulty in synthesizing and generalizing the results of these studies derives from the heterogeneity of measurement instruments used to evaluate these outcomes. It is critical for the community of transplant physicians to use validated generic and diseasespecific QOL instruments, utility-based measures of QOL, and established employment classifications. For
example, because utility-based measures have not been used with liver transplant recipients, the necessary quality weights for use in cost-effectiveness evaluations of liver transplantation are lacking. Despite these limitations, there is a clear consensus in the current literature that as the severity of patients’ end-stage liver disease increases, their QOL and ability to remain employed decreases. In addition, as they recover from their liver transplantation procedures, many patients report significant improvements in QOL, and some are able to return to work. Interestingly, despite differences in culture and race/ethnicity that would be expected to influence work patterns and perceptions of QOL, these findings have been found among transplant recipients from Japan,18 Taiwan,19 Sweden,20 and the United States.4,5 Further research that provides detailed descriptions of the groups of patients for whom QOL is not improved and return to satisfying employment is not possible is needed. Additionally, studies of the influence of healthcare providers and social support interventions on transplant recipients’ QOL should be conducted to design posttransplantation programs that maximize favorable outcomes for transplant recipients.
References 1. Surman OS, Dienstag JL, Cosimi AB, Chauncey S, Russell PS. Psychosomatic aspects of liver transplantation. Psychother Psychosom 1987;48:26-31. 2. Surman OS. Psychiatric aspects of liver transplantation. Psychosomatics 1994;35:297-307. 3. Seaberg EC, Belle SH, Beringer KC, Schivins JL, Detre KM. Long-term patient and retransplantation-free survival by selected recipient and donor characteristics: An update from the PittUNOS liver transplant registry. In: Cecka JM, Terasaki PI (eds). Clinical transplants 1997. Los Angeles, CA: UCLA Tissue Typing Laboratory, 1998:15-28. 4. Bravata DM, Olkin I, Barnato AE, Keeffe EB, Owens DK. Health-related quality of life after liver transplantation: A metaanalysis. Liver Transpl Surg 1999;5:318-331. 5. Bravata DM, Olkin I, Barnato AE, Keeffe EB, Owens DK.
QOL and Employment After OLT
6.
7. 8. 9.
10.
11.
12.
Employment and alcohol use after liver transplantation for alcoholic and nonalcoholic liver disease: A systematic review. Liver Transpl 2001;7:191-203. Bravata DM, Keeffe EB, Owens DK. Quality of life, employment and alcohol consumption after liver transplantation. Curr Opin Organ Transplant 2001;6:130-141. McDowell I, Newell C. Measuring health: A guide to rating scales and questionnaires, vol 1 (ed 2). New York: Oxford, 1996. Hicks FD, Larson JL, Ferrans CE. Quality of life after liver transplant. Res Nurs Health 1992;15:111-119. Belle SH, Porayko MK, Hoofnagle JH, Lake JR, Zetterman RK. Changes in quality of life after liver transplantation among adults. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database (LTD). Liver Transpl Surg 1997;3:93-104. Gralnek IM, Hays RD, Kilbourne A, Rosen HR, Keeffe EB, Artinian L, et al. Development and evaluation of the Liver Disease Quality of Life Instrument in persons with advanced, chronic liver disease—The LDQOL 1.0. Am J Gastroenterol 2000;95:3552-3565. Pereira SP, Howard LM, Muiesan P, Rela M, Heaton N, Williams R. Quality of life after liver transplantation for alcoholic liver disease. Liver Transpl 2000;6:762-768. Mejias D, Ramirez P, Rios A, Munitiz V, Hernandez Q, Bueno F, et al. Recurrence of alcoholism and quality of life in patients
13.
14.
15.
16.
17. 18.
19.
20.
S123
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