Return to Work After Heart Transplantation: The New ZealandExperience

C.B. Samaranayake, P.N. Ruygrok, C.A. Wasywich, and H.A. Coverdale

0041-1345/1http://dx.doi

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ABSTRACT

Introduction. Return to work and social re-integration following heart transplantation isa significant challenge for patients. The aim of this study is to provide a snapshot of thecurrent employment status and factors associated with return to work in New Zealandrecipients over the past decade.Methods. Consecutive surviving patients who underwent heart transplantation in the 10years from June 2001 to June 2011, alive in July 2012, were retrospectively identified.Details on demographics, employment before and after transplantation were obtained andrecorded.Results. A total of 87 patients were included, out of a total of 111 patients who under-went heart transplantation in the 10 year period from June 2001 (24 patients had died priorto July 2012). The median age of the study cohort was 52 years (range 15e75 years) and 19were female. A total of 51 (58.6%) patients were in paid employment at the time of review.Of the 36 (41.4%) patients not in paid employment, 5 were students, 12 were retired and10 were homemakers or not working through lifestyle choice. Two patients were unable towork for health reasons. Seven (8%) patients considered able to work were on an unem-ployment or invalid’s benefit. Of the patients working prior to heart transplantation, 88.9%returned to work after a median of 8.5 months, and 70.6% remained on paid employmentat a median follow-up of 77 months after transplantation. There was a statisticallysignificant correlation between the time of stopping work prior to transplant and returnto work after transplant (r ¼ 0.497, P < .01).Conclusion. The current rate of paid employment in patients who underwent hearttransplantation was similar to the overall employment rate in New Zealand. The mostimportant predictor of returning to work was employment status prior to transplantation.Discussions regarding return to work early in the transplantation assessment process andactively assisting patients to seek employment after transplantation may improveemployment rates.

From the Green Lane Cardiovascular Service (C.B.S., P.N.R.,C.A.W., H.A.C.), Auckland City Hospital, Auckland, New Zealand;and The University of Auckland (P.N.R.), Auckland, New Zealand

Address correspondence to Dr Chinthaka Bhagya Samar-anayake, Green Lane Cardiovascular Service, Auckland CityHospital, Private Bag 92024, Auckland 1142, New Zealand.E-mail: csam020@aucklanduni.ac.nz

SOCIAL re-integration and return to work are normalaspirations for patients following heart transplantation

and these important secondary outcomes are activelypromoted by the transplant multidisciplinary team.Obtaining meaningful employment is commonly associatedwith achievement of personal goals, financial independenceand self esteem and, in the community’s perception, isa visible endorsement of a transplant program’s value.1,2

Heart transplant patients who returned to work have beenfound to have fewer physical and psychosocial disabilitiesand an increased quality of life.3e5

3/$esee front matter.org/10.1016/j.transproceed.2012.12.033

In some centers, the rate of return to work followingheart transplantation has been lower than expected, rangingbetween 20% to 80%.6e8 The aim of this study was to

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Transplantation Proceedings, 45, 2410e2413 (2013)

Table 1. Demographic Details of the Study Population

Total number of study participants 87Age at the time of transplant [median (range)] 45 (12e65) yAge at the time of study [median (range)] 52 (15e75) yTime since transplantation [median (range)] 77 (13e113) moWomen N (%) 19 (20.8)Ethnicity

NZ European N (%) 67 (77)Maori N (%) 13 (14.9)Pacific Islander N (%) 3 (3.4)Asian N (%) 4 (4.6)

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provide a snapshot of the current employment status andfactors associated with returning to work in patients whohad undergone heart transplantation in New Zealand overthe last 10 years.

METHOD

Consecutive surviving patients who underwent heart trans-plantation in New Zealand in the 10-year period from June 2001 toJune 2011 were identified in July 2012. Demographic details,current employment information, nature of employment prior totransplant, duration of unemployment prior to transplant, time toreturn to employment and type of work undertaken followingtransplantation were gathered from data collected during clinicvisits and clinical records. The transplant coordinator contactedpatients by telephone when data were unavailable from clinicalrecords or if they had not been seen at the transplant clinic in theprevious 12 months. Approval from the Health and DisabilityEthics Committee of New Zealand was not required for thisobservational study.

Current employment status of the patients was classified into thefollowing categories; full-time (in paid employment and workingover 30 hours per week), part-time (in paid employment andworking less than 30 hours per week), studying (secondary ortertiary studies), retired (not in paid employment and over the ageof 65 years), homemaker (in working age but managing householdand/or children’s tasks and not receiving a benefit or not workingdue to lifestyle choice), unemployed due to health (unable to workdue to health reasons and receiving sickness or invalids benefit), andunemployed (receiving the unemployment benefit). Patients whowere in paid employment were then sub-grouped based on type ofoccupation as per the Australian and New Zealand StandardClassification of Occupations.9

Data Analysis

The rates of current employment status and occupation cate-gories were calculated, and proportions in subgroups based onage, gender and ethnicity were compared using the chi-squaredtest where applicable. The median time of unemployment priorto transplantation and median time to return to work followingtransplant were calculated. Spearman correlation was used toquantify associations between the time periods of unemploymentprior to transplant with time to return to work (nonparametricdata). Cumulative time to return to work was assessed usingCox’s regression analysis. Factors associated with returning towork and rates of patients returning to a similar occupationpost transplantation were assessed. The 95% confidence inter-vals (95% CI) were calculated for rates, and the reporteddifferences were significant at P value <.05. The analyseswere carried out using Statistical Package for the Social Sciences2010 (SPSS for Windows, release 19.0.0, IBM Corporation,Somers, NY, USA).

RESULTS

A total of 111 patients underwent heart transplantation inthe 10 years from June 2001 in New Zealand. Of this group24 (23%) patients had died at the time of review (July2012), leaving 87 for inclusion in the study. The median ageof the study participants was 52 years (range 15 to 75 years)and females represented 20.8% of the patients. Table 1

summarizes the other demographic details of the patientswho were included.

Current Employment Status

A total of 51 (58.6%) patients were in paid employment atthe time of the study. The majority were in full time paidemployment (86.3%), while 13.7% worked part time. Of thepatients who were not in paid employment, 5 (5.7%) werestudents, 12 (13.8%) were retired and 10 (11.5%) werehomemakers or not working through lifestyle choice. Two(2.3%) patients were unable to work for health reasons.A total of 7 patients (8.0%) considered able to work, wereunemployed.Table 2 summarises the employment status of the study

participants based on gender, ethnicity and age group. Astatistically significant proportion of women were home-makers compared to males (31.6% vs 5.9%, P < .01), andonly male patients were in the unemployed category.Statistically less New Zealand European patients were on anunemployed benefit compared to other ethnicities (P < .05).Asian patients were more likely to be homemakerscompared to other ethnicities, however the number of Asianpatients was too small for valid statistical comparison.Regarding occupation category, the majority of the

patients worked in jobs that are classified as ‘administratorsor managers’ and ‘technicians and trade workers’. Signifi-cantly more female patients were in clerical and admin-istrative occupations (21.1% females versus 1.5% males,P < .01). No other statistically significant differences werefound in subgroup analysis regarding occupation typebetween males and females. Table 3 summarises the type ofoccupation of the patients based on the Australian and NewZealand Standard Classification of Occupations.

Employment Prior to Transplant

A total of 68 (78.1%) patients were in paid employmentprior to heart transplantation; 10 other patients werestudents, 5 were homemakers, 3 were unemployed and onewas retired. The median time to stopping employment priorto heart transplantation was 9.5 months (range <1 to 180months). The majority (91%) of the patients who were inpaid employment stopped working due to physical limita-tion from their cardiac condition and 9% were working tosome degree up until their operation.

Table 2. Current Employment Status Based on Gender, Ethnicity, and Age Group

Category Fulltime Part-time Student Retired Homemaker Not working due to health Unemployed

GenderFemale N (%) 7 (36.8) 3 (15.6) 1 (5.3) 2 (10.5) 6 (31.6) 0 (0) 0 (0)Male N (%) 37 (54.4) 4 (5.9) 4 (5.9) 10 (14.7) 4 (5.9) 2 (2.9) 7 (10.3)

EthnicityNZ European N (%) 37 (55.2) 7 (10.4) 4 (6.0) 11 (16.4) 5 (7.5) 1 (1.5) 2 (3.0)Maori N (%) 5 (38.5) 0 (0) 1 (7.7) 1 (7.7) 2 (15.4) 1 (7.7) 3 (23.1)Pacific N (%) 2 (66.7) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (33.3)Asian N (%) 0 (0) 0 (0) 0 (0) 0 (0) 3 (75.0) 0 (0) 1 (25.0)

Age groups11e20 y N (%) 1 (33.3) 0 (0) 2 (66.7) 0 (0) 0 (0) 0 (0) 0 (0)21e30 y N (%) 7 (58.3) 0 (0) 2 (16.7) 0 (0) 1 (8.3) 1 (8.3) 1 (8.3)31e40 y N (%) 3 (60) 1 (20) 1 (20) 0 (0) 0 (0) 0 (0) 0 (0)41e50 y N (%) 16 (80) 1 (5) 0 (0) 0 (0) 1 (5) 0 (0) 2 (10)51e60 y N (%) 14 (63.6) 1 (4.5) 0 (0) 0 (0) 6 (27.4) 0 (0) 1 (4.5)61e70 y N (%) 3 (15.0) 3 (15.0) 0 (0) 8 (40) 2 (10) 1 (5) 3 (15)71e80 y N (%) 0 (0) 1 (20) 0 (0) 4 (80) 0 (0) 0 (0) 0 (0)

2412 SAMARANAYAKE, RUYGROK, WASYWICH ET AL

Employment After Transplant

A total of 60 (88.3%) patients who were working prior totransplant returned to work after heart transplantation. Themedian time to return to employment was 8.5 months(range 2 to 52 months). Of the patients who were workingprior to transplant, but did not return to work after trans-plantation, 2 patients had retired, 5 patients becamehomemakers or not worked due to lifestyle choice, and 1patient became unemployed and received an unemploymentbenefit. A total of 48 (70.6%) patients who were workingprior to transplant remained on paid employment aftera median follow-up of 77 months (range 13 to 113 months).There was a statistically significant but modest correlation

between the time to return to work after transplant and timeof stopping work prior to transplant (r ¼ 0.497, P < .01).There was no correlation between age at the time oftransplant and return to work post transplant. Figure 1shows the cumulative time to return to work after trans-plantation, and highlights that over 50% of patients whoreturned to work did so within 10 months of transplant. Themajority (84.1%) of patients returned to the same type ofwork after transplantation. Of those who changed their typeof work, most changed from a more physical to a lessphysical occupation.

Table 3. Classification of Type of Occupation of Patients WhoAre Working

Type of Work NPercentage of patients

who are currently working

Administrators or manager 10 19.6Professionals 7 13.7Technicians and trades workers 11 21.6Community and personal service

workers2 3.9

Clerical and administrative workers 4 7.8Sales workers 7 13.7Machinery operators and drivers 4 7.8Laborers 6 11.8

DISCUSSION

In this study, the current rate of paid employment in thepatients who underwent heart transplantation in New Zea-land the 10 year period from June 2001 to June 2011 was58.6%. This rate is similar to the 63.8% employment rate inthe New Zealand working age general population in theJune 2012 quarter.10 The rate of unemployment in the study(8.0%) was also similar to the 6.8% unemployment rate inNew Zealand in the June 2012 quarter.10 The most impor-tant predictor of employment after transplantation was theemployment status prior to surgery. We found that 88.9% ofpatients working prior to heart transplantation returned towork after a median duration of 8.5 months after transplant,and 70.6% remained in paid employment at a medianfollow-up of 77 months after transplantation. Of the 19patients not in paid employment prior to transplant, only 3patients (15.8%) were in paid employment at the time of thestudy (these patients completed their studies after

Fig. 1. Cumulative rate of return to work after heart transplanta-tion (n ¼ 60).

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transplantation and subsequently found paid work). Therewas a statistically significant but moderate correlationbetween the time period of stopping work prior to trans-plant and the time to return to work after transplant.However there was no association between age andreturning to work in this study population.The rate of employment in the New Zealand heart trans-

plant population is higher than the rates reported in otherrecent studies.4,11,12 Our rates of return to work are similar orhigher than other solid organ transplant patients. In a recentstudy looking at solid organ transplant patients, De Baereet al found a return to work rate of 58.6% in kidney, 43.6% inheart, 37.5% in liver and 28.1% in lung transplant patients.13

One possible reason for the higher rate of employment in ourstudy is the relative stability of the New Zealand economy ina period of global economic recession. Furthermore, ourprogram strongly encourages recipients to return to paidemployment after transplantation if at all possible and thismay contribute to the higher rates of employment in ourpopulation, compared to other transplant centres.14 Asreported in previous studies, performing formal assessmentof the patients’ educational background, skills, previous workexperience and functional and physical limitations as well asformulating career plans with the patients result in greaternumber of patients returning to work.8 Active discussionswith patients regarding post transplantation regardingemployment at the time of assessment and establishing thisas a goal following recovery, has also been found to increasethe rate of employment.15

This study has several limitations. First, the lack ofprospective longitudinal data on individual patientsprevents the authors from making strong conclusionsregarding the long-term rate of employment of the patients.Other factors that affect successful social re-integrationwere not measured in this study. Previous studies have re-ported correlations between depression, educational leveland functional capacity with the rate of employment intransplant patients.3 Furthermore, in a country with a wellestablished social welfare system, such as in New Zealand,the rate of employment is not a direct measure of quality oflife as some previous studies suggest.16 We can, however,infer that the relatively high rate of return to work in ourpatients is a valuable secondary outcome and is one of manyfactors contributing to the improved quality of life ofpatients after heart transplantation.

SUMMARY

The current rate of paid employment in patients whounderwent heart transplantation in New Zealand over thelast 10 years was 58.6%, and the rate of unemployment was8.0%. These rates are similar to the reported employmentand unemployment rates in New Zealand; 63.8% and 6.8%,

respectively. The majority of the patients who were workingprior to transplantation returned to work and remained inpaid employment after 6 years following transplantation.Employment is an important secondary outcome of thetransplant process and return to work and maintainingmeaningful employment after heart transplantation shouldbe discussed before transplantation and used as one of thegoals of post-operative rehabilitation.

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