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
Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
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
233
234
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 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
HUDA, NEWCOMER, HARRINGTON ET AL
were 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 (
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
Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
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
233
234
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 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
HUDA, NEWCOMER, HARRINGTON ET AL
were 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 (
