Return to Work and Employment Income After Stroke

Abstract

Background: Stroke is a leading cause of disability worldwide. Many people after stroke experience functional limitations and have difficulty returning to work. Returning to work after stroke is important for financial reasons, but also for mental health and life satisfaction. Health professionals may assume that many stroke rehabilitation patients do not expect to return to work and decide to retire. This may be a false assumption. Knowing the proportion of stroke rehabilitation patients who intend to return to work can help rehabilitation providers to better understand their patients' plans and to initiate discussion about return to work needs. Furthermore, healthcare and social service providers have limited information regarding the proportion of stroke survivors who do return to work. Estimates of return to work poststroke widely vary in the literature, and it is not clear how operational definitions have affected these estimates. Finally, Ontario healthcare and social service providers and planners could benefit from population-based estimates of return to work and poststroke employment income. Purpose and Objectives: The overall purpose of my thesis research was to investigate return to work after stroke. The specific objectives were to: 1) estimate the proportion of stroke rehabilitation inpatients intending to return to work; 2) examine operational definitions of return to work, and more precisely estimate the proportion of stroke survivors returning to work; and 3) determine the relative effects of stroke on the probability of reporting employment income over 3 years, and estimate the changes in annual employment income attributable to stroke. Methods: To meet these objectives, I conducted three studies: 1) a cross-sectional study using hospital data from the Canadian Institute for Health Information National Rehabilitation Reporting System; 2) a systematic review and meta-analysis; and 3) a retrospective cohort study using hospital data from the Canadian Institute for Health Information Discharge Abstract Database linked with personal income tax data from Statistics Canada. Results: Study 1, the cross-sectional study, showed that in Ontario 43.7% of stroke rehabilitation inpatients who worked prestroke, including 36.2% of those over the traditional retirement age of 65 years, intended to return to work. The finding adds to our understanding of the potential return to work service needs of stroke rehabilitation inpatients in Ontario. Study 2, the systematic review, found that almost all operational definitions of return to work were based on full-time or part-time paid employment (46 of 47 studies). Follow-up time differed across studies, from less than 1 month to 18 years poststroke. Meta-analyses using data from studies with similar lengths of follow-up revealed that the proportions of people returning to work poststroke were 55.7% at 1 year (95% CI; 51.3-60.0) and 67.4% at 2 years (95% CI; 60.4-74.4). These estimates can serve as benchmarks to monitor the effects of future improvements in programs and social services on return to work. Study 3, the retrospective cohort study, demonstrated that in Ontario the percentages of people working in the year prestroke reporting employment income poststroke were 74.8% at 1 year (95% CI; 73.1-76.5), 68.1% at 2 years (95% CI; 66.3-69.9), and 63.4% at 3 years (95% CI; 61.6-65.3). Stroke survivors were less likely to report any employment income compared to people without stroke of similar demographic characteristics, incidence rate ratios 0.87 at 1 year (95% CI; 0.85-0.88), 0.82 at 2 years (95% CI; 0.81 0.84) and 0.81 at 3 years (95% CI; 0.79-0.82). Relative changes in annual employment income attributable to stroke varied from a decrease of 13.8% (95% CI; 8.7-18.9) at the 75th income percentile to a decrease of 43.1% (95% CI; 18.7-67.6) at the 25th income percentile. Conclusions: Providers should initiate early discussions about return to work with stroke rehabilitation inpatients. It should not be assumed that older patients will be retiring, or that returning to work is not a priority. To help address return to work and the consequences of loss of income, rehabilitation providers should connect stroke survivors with employment and social services, especially those in low-income situations. While Ontario estimates of return to work after stroke are higher than international averages, there is a troubling trend of employment decreasing over time, rather than increasing over time, as seen in the international data. Rehabilitation providers should make effort to start early and to follow up with stroke survivors who return to work to ensure employment is maintained.