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1.  Self-reported sickness absence as a risk marker of future disability pension. Prospective findings from the DWECS/DREAM study 1990-2004 
Objectives: This prospective cohort study examines number of self-reported days of sickness absence as a risk marker for future disability pension among a representative sample of employees in Denmark 1990-2004.
Material and methods: 4177 employees between 18 and 45 years were interviewed using a self-administered questionnaire in 1990 regarding sickness absence, age, gender, socioeconomic position, health behaviour, and physical and psychosocial work environment. They were followed for 168 months in a national disability pension register. Logistic regression analysis was performed in order to assess risk estimates for levels of absence and future disability pension.
Results: During follow-up, a total of 140 persons (3.4%) received disability pension. Of these, 82 (58.6%) were women, 58 (41.4%) were men. There was a 2.5 fold risk of future disability pension for the part of the population reporting more than 6 days of sickness absence per annum at baseline, when taking into account gender, age, socioeconomic position, health behaviour, physical and psychosocial work environment.
Conclusion: The findings suggest that information on self-reported days of sickness absence can be used to effectively identify “at risk” groups for disability pension.
PMCID: PMC1885553  PMID: 17554400
Sickness absence; self-reported; disability pension; prospective; Denmark
2.  Partial sick leave associated with disability pension: propensity score approach in a register-based cohort study 
BMJ Open  2012;2(6):e001752.
To support sustainability of the welfare society enhanced work retention is needed among those with impaired work ability. Partial health-related benefits have been introduced for this target. The aim was to estimate the effects of partial sick leave on transition to disability pension applying propensity score methods.
Register-based cohort study.
Sample from the national sickness insurance registers representative of the Finnish working population (full-time workers) with long-term sickness absence due to musculoskeletal disorders, mental disorders, traumas or tumours.
All recipients of partial or full sickness benefit whose sick leave period had ended between 1 May and 31 December 2007 were included. The sample was limited to four most prevalent diagnostic groups—mental and musculoskeletal disorders, traumas and tumours. The total sample consisted of 1047 subjects on partial sick leave (treatment group) and 28 380 subjects on full sick leave (control group). A subsample (1017 and 25 249 subjects, respectively) was formed to improve the comparability of the two groups.
Outcome measures
A three-category measure and a binary measure for the occurrence of disability pension on the last day of 2008 were computed.
Partial sickness benefit reduced the risk (change in absolute risk) of full disability pension by 6% and increased the risk of partial disability pension by 8% compared with full sick leave. The effects did not differ markedly for the two main diagnostic groups of musculoskeletal and mental disorders. In men, the use of full disability pension was reduced by 10% with a 5% increase in the use of partial disability pension, while in women the effects were close to those of the total sample.
Our findings suggest that combining work with partial sick leave may provide one means to increase work retention at population level. The use of partial sick leave could be encouraged among men.
PMCID: PMC3533026  PMID: 23144260
Epidemiology; Public Health; Population Registers
3.  Diagnosis‐specific sick leave as a risk marker for disability pension in a Swedish population 
To investigate diagnosis‐specific sick leave as a risk marker for subsequent disability pension.
A prospective population based cohort study. Exposure to a new medically certified sick leave episode of more than seven days by diagnosis during 1985 was examined in relation to incident cause‐specific disability pension through 1996.
The total non‐retired population of one Swedish county aged 16 to 49 years, alive and not in receipt of a disability pension at the end of 1985 (176 629 persons; 51% men).
Main results
To eliminate confounding by sick leaves that translate into a disability pension, the follow up period for disability pension was started five years after the assessment of sick leave. After adjustment for demographic characteristics, the risk of disability pension from mental disorders was 14.1 times higher (95% confidence interval (CI), 12.1 to 16.4) for those with sick leave for mental disorders than for those with no sick leave. The corresponding hazard ratio for sick leave and disability pension within diagnostic category was 5.7 (95% CI, 5.3 to 6.2) for musculoskeletal diseases and 13.0 (7.7 to 21.8) for gastrointestinal diseases. Irrespective of diagnoses, the hazard ratio for sick leave and disability pension was 3.0 (2.9 to 3.1).
Sick leave may provide an important risk marker for identifying groups at high risk of a disability pension, especially for psychiatric diagnoses.
PMCID: PMC2652975  PMID: 17873230
disability; pensions; ill health retirement; sickness absence; mental health
4.  Sick-leave track record and other potential predictors of a disability pension. A population based study of 8,218 men and women followed for 16 years 
BMC Public Health  2009;9:104.
A number of previous studies have investigated various predictors for being granted a disability pension. The aim of this study was to test the efficacy of sick-leave track record as a predictor of being granted a disability pension in a large dataset based on subjects sampled from the general population and followed for a long time.
Data from five ongoing population-based Swedish studies was used, supplemented with data on all compensated sick leave periods, disability pensions granted, and vital status, obtained from official registers. The data set included 8,218 men and women followed for 16 years, generated 109,369 person years of observation and 97,160 sickness spells. Various measures of days of sick leave during follow up were used as independent variables and disability pension grant was used as outcome.
There was a strong relationship between individual sickness spell duration and annual cumulative days of sick leave on the one hand and being granted a disability pension on the other, among both men and women, after adjustment for the effects of marital status, education, household size, smoking habits, geographical area and calendar time period, a proxy for position in the business cycle. The interval between sickness spells showed a corresponding inverse relationship. Of all the variables studied, the number of days of sick leave per year was the most powerful predictor of a disability pension. For both men and women 245 annual sick leave days were needed to reach a 50% probability of transition to disability. The independent variables, taken together, explained 96% of the variation in disability pension grantings.
The sick-leave track record was the most important predictor of the probability of being granted a disability pension in this study, even when the influences of other variables affecting the outcome were taken into account.
PMCID: PMC2674437  PMID: 19368715
5.  Work disability benefits due to musculoskeletal disorders among Brazilian private sector workers 
BMJ Open  2011;1(1):e000003.
To evaluate the prevalence and characteristics of disability benefits due to musculoskeletal disorders (MSD) granted to Brazilian private sector workers.
This was a population-based epidemiological study of MSD-related benefits among registered private sector workers (n=32 959 329). The prevalence (benefits/10 000 workers/year) of work disability benefits was calculated by gender, age, state, Human Development Index (HDI), economic activity, MSD type and work-relatedness.
The prevalence of MSD-related benefits in Brazil among registered private sector workers in 2008 was 93.6/10 000 workers. The prevalence increased with age, and was higher for women (112.2) than for men (88.1), although the former had shorter benefit duration. The gender-adjusted prevalence by state varied from 16.6 to 90.3 for non-work-related, and from 7.8 to 59.6 for work-related benefits. The Brazilian states with a high–very high HDI had the highest prevalence. The top four most common types of MSD-related benefits were due to back pain, intervertebral disc disorders, sinovitis/tenosynovitis and shoulder disorders.
MSD is a frequent cause of work disability in Brazil. There were differences in prevalence among economic activities and between states grouped by HDI. This study demonstrates that further evaluation of the contributing factors associated with MSD-related disability benefits is required. Factors that should be considered include production processes, political organisation, socioeconomic and educational characteristics, the compensation and recording systems, and employee–employer power relationships. These factors may play an important role in the prevalence of MSD-related disability benefits, especially in countries with large socioeconomic iniquities such as Brazil.
Article summary
Article focus
Musculoskeletal disorders (MSD) are a major cause of disability worldwide.
The prevalence and distribution of MSD among Brazilian workers are not well known.
This article evaluates the prevalence and characteristics of disability benefits due to MSD granted to Brazilian private sector workers.
Key messages
The prevalence of MSD-related benefits among registered Brazilian private sector workers in 2008 was 93.6/10 000 workers, with the top four most common benefits being due to back pain, intervertebral disc disorders, sinovitis/tenosynovitis and shoulder disorders.
This study demonstrates that further evaluation of the contributing factors associated with MSD-related disability benefits is required and should assess the production processes, political organisation, socioeconomic and educational characteristics, the compensation and recording systems, and employee–employer power relationships.
These factors may play an important role in the prevalence of MSD-related disability benefits, especially in countries with large socioeconomic iniquities such as Brazil.
Strengths and limitations of this study
All employed workers with a registered job in the private sector were analysed (32 959 329 workers). Prevalence was adjusted by gender, age and category of benefit (work-related or non-work-related). This initial descriptive study provides some baseline data on the magnitude of the problem. The data may be used for future comparisons and to evaluate the effectiveness of prevention programs. The strength of this paper is that it supplies information which could be useful in the implementation of an occupational health policy to reduce MSD. One of the limitations is that it only includes data from registered workers although there are many non-registered workers in Brazil. Another limitation is that this study depends on the quality of the data recorded by the National Insurer (NI) of the Brazilian Ministry of Social Insurance.
PMCID: PMC3191405  PMID: 22021719
6.  Self-reported treatment, workplace-oriented rehabilitation, change of occupation and subsequent sickness absence and disability pension among employees long-term sick-listed for psychiatric disorders: a prospective cohort study 
BMJ Open  2012;2(6):e001704.
To examine whether self-reported treatments, workplace-oriented rehabilitation and change of occupation were associated with subsequent sickness absence and disability pension among long-term sick-listed for psychiatric disorders.
A prospective cohort study.
Setting and participants
5200 employees (80% from the Swedish municipalities and county councils and 20% manual workers from the Swedish industry) were randomly selected who in 1999 in the register of AFA Insurance had a new spell of long-term sickness absence due to a psychiatric disorder. Of these, 99 were excluded (duplicates and deaths, persons living abroad, with protected personal information), and 5101 received a questionnaire in 2001. 3053 individuals responded (60%). After the exclusion of employees with no sick leave in 1999 according to the Swedish social insurance agency, aged 62 years and older, with disability pension 1999–2001, no self-reported treatment, and with missing information on the covariates, our final study group was 2324 individuals. Logistic regression analyses were performed.
Outcome measures
Sickness absence (>90 days) and disability pension (>0 day).
45% had sickness absence and 18% a new disability pension in 2002. Drug treatment and physiotherapy, respectively, were associated with increased odds of sickness absence (OR 1.56, 95% CI 1.28 to 1.90; OR 1.43, 95% CI 1.21 to 1.69), and disability pension (OR 1.79, 95% CI 1.34 to 2.41; OR 1.75, 95% CI 1.40 to 2.18). Workplace-oriented rehabilitation and change of occupation, respectively, reduced the odds of sickness absence (OR 0.70, 95% CI 0.59 to 0.83; OR 0.35, 95% CI 0.27 to 0.45).
We found a pattern of poorer outcome of drug treatment and physiotherapy compared with other treatments (psychotherapy, workplace-oriented rehabilitation and complementary or alternative medicine) in terms of increased odds of sickness absence and disability pension. Workplace-oriented rehabilitation and/or change of occupation were associated with reduced odds of sick leave. Studies with a randomised controlled trial design are needed to examine the effect on sick leave of a workplace-oriented intervention.
PMCID: PMC3533007  PMID: 23117569
Rehabilitation Medicine; Public Health
7.  Sickness absence as a risk factor for job termination, unemployment, and disability pension among temporary and permanent employees 
This study examined sickness absence as a risk factor for job termination, unemployment, and disability pension among temporary and permanent workers.
Prospective cohort study with data on employment contract and sickness absence in 1996, job termination by 1997, and employment status in 1997 and 2000 for 19 093 temporary and 41 530 permanent public sector employees.
For women aged 40 years or less and for women over 40, a high sickness absence increased the risk of job termination among temporary employees (OR 1.52 (95% CI 1.36 to 1.71) and OR 1.70 (95% CI 1.36 to 2.13) respectively). High absence was not associated with job termination among men in temporary employment. Among permanent employees, high sickness absence predicted job termination among older, but not among younger employees. Temporary employees with high sickness absence were at the highest risk of immediate unemployment and unemployment three years later. Among older permanent employees, high sickness absence was associated with subsequent work disability pension.
A high rate of sickness absenteeism increases the risk of job termination and unemployment among women in temporary public sector jobs. For permanent employees, secure employment provides protection against unemployment even in the case of high sickness absence.
PMCID: PMC2078149  PMID: 16497865
employment status; health selection; job insecurity; longitudinal study; sickness absence
8.  Employee control over working times and risk of cause-specific disability pension: the Finnish Public Sector Study 
To examine the association between worktime control and subsequent retirement on health ground (disability pension) among employees.
A prospective cohort study of 30 700 public sector employees (78% women) aged 18 to 64 at baseline. Two scores of worktime control, self-assessed and co-worker assessed, were obtained from responses to the baseline survey in 2000-2001 (score range 1 to 5). Information on cause-specific disability pension during follow-up was collected from national registers.
During a mean follow-up of 4.4 years, 1178 employees were granted disability pension (incidence per 1000 person-years 9.2 in women and 8.7 in men). The most common causes of a disability pension were musculoskeletal disorders (43% of all pensions), mental disorders (25%), tumours (8%), and diseases of the circulatory system (6%) and the nervous system (6%). A 1 unit increase in self-assessed and co-worker assessed worktime control score was associated with a 41-48% lowering of the risk of disabling musculoskeletal disorders in men and 33-35% lowering in women. This association was robust to adjustment for all 17 baseline covariates (in men and women combined, adjusted hazard ratio 0.76, 95% CI 0.67-0.87 and 0.64, 95% CI 0.51-0.79 per 1 unit increase in self-assessed and co-worker assessed worktime control, respectively).Self-assessed worktime control was also associated with the risk of disability retirement due to mental disorders in women, but this association was not replicated using co-workers’ assessment. Disability pensions from other disease categories were not related to control over working times.
In this cohort of public sector employees, high worktime control among employees was associated with reduced risk of early retirement caused by musculoskeletal disorders independent of baseline characteristics.
PMCID: PMC3226939  PMID: 19914911
9.  Associations between partial sickness benefit and disability pensions: initial findings of a Finnish nationwide register study 
BMC Public Health  2010;10:361.
Timely return to work after longterm sickness absence and the increased use of flexible work arrangements together with partial health-related benefits are tools intended to increase participation in work life. Although partial sickness benefit and partial disability pension are used in many countries, prospective studies on their use are largely lacking. Partial sickness benefit was introduced in Finland in 2007. This register study aimed to investigate the use of health-related benefits by subjects with prolonged sickness absence, initially on either partial or full sick leave.
Representative population data (13 375 men and 16 052 women either on partial or full sick leave in 2007) were drawn from national registers and followed over an average of 18 months. The registers provided information on the study outcomes: diagnoses and days of payment for compensated sick leaves, and the occurrence of disability pension. Survival analysis and multinomial regression were carried out using sociodemographic variables and prior sickness absence as covariates.
Approximately 60% of subjects on partial sick leave and 30% of those on full sick leave had at least one recurrent sick leave over the follow up. A larger proportion of those on partial sick leave (16%) compared to those on full sick leave (1%) had their first recurrent sick leave during the first month of follow up. The adjusted risks of the first recurrent sick leave were 1.8 and 1.7 for men and women, respectively, when subjects on partial sick leave were compared with those on full sick leave. There was no increased risk when those with their first recurrent sick leave in the first month were excluded from the analyses. The risks of a full disability pension were smaller and risks of a partial disability pension approximately two-fold among men and women initially on partial sick leave, compared to subjects on full sick leave.
This is the first follow up study of the newly adopted partial sickness benefit in Finland. The results show that compared to full sick leave, partial sick leave - when not followed by lasting return to work - is more typically followed by partial disability pension and less frequently by full disability pension. It is anticipated that the use of partial benefits in connection with part-time participation in work life will have favourable effects on future disability pension rates in Finland.
PMCID: PMC2912806  PMID: 20573207
10.  Sickness Absence Due to Otoaudiological Diagnoses and Risk of Disability Pension: A Nationwide Swedish Prospective Cohort Study 
PLoS ONE  2012;7(1):e29966.
Hearing difficulties are a large public health problem. Knowledge is scarce regarding risk of disability pension among people who have been sickness absent due to these difficulties.
A cohort including all 4,687,756 individuals living in Sweden in 2005, aged 20–64, and not on disability or old-age pension, was followed through 2009. Incidence rate ratios (RR) of disability pension with 95% confidence intervals (CI) were estimated using Cox proportional hazard models.
In multivariable models, individuals who had a sick-leave spell due to otoaudiological diagnoses in 2005 had a 1.52-fold (95% CI: 1.43–1.62) increased risk of being granted a disability pension compared to individuals on sick leave due to other diagnoses. Hearing and tinnitus sick-leave diagnoses were associated with risk of disability pension: RR 3.38, 95% CI: 3.04–3.75, and 3.30, 95% CI: 2.95–3.68, respectively. No association was observed between sick leave due to vertigo diagnoses and disability pension whereas otological diagnoses and no sick leave were inversely associated with risk of disability pension compared to non-otoaudiological sick-leave diagnoses. Sick leave due to otoaudiological diagnoses was positively associated with risk of disability pension due to otoaudiological diagnoses and sick leave due to a tinnitus diagnosis was also associated with risk of disability pension due to mental diagnoses. The risk of disability pension among individuals with hearing or tinnitus sick-leave diagnoses was highest in the age group 35–44. Moreover, men had a slightly higher risk.
This large cohort study suggests an increased risk of disability pension among those with sickness absence due to otoaudiological diagnoses, particularly hearing and tinnitus diagnoses, compared to those with sickness absence due to non-otoaudiological diagnoses.
PMCID: PMC3257229  PMID: 22253839
11.  Diagnosis-specific sickness absence and all-cause mortality in the GAZEL study 
To examine diagnosis-specific sickness absence as a risk marker for all-cause mortality.
Prospective occupational cohort (the GAZEL study). Medically-certified sickness absence spells greater than 7 days for 15 diagnostic categories, 1990–1992, were examined in relation to all-cause mortality, January 1993-February 2007. The reference group for each diagnostic category was participants with no spell >7 days for that diagnosis.
French public utility workers (5,271 women and 13,964 men) aged 37–51 in 1990, the GAZEL study. Over the follow-up period there were 144 deaths in women and 758 in men.
Main results
7,875 employees (41.0%) had at least one spell of sickness absence >7 days over the three-year period. The commonest diagnoses were mental disorders, musculoskeletal diseases, respiratory diseases and external causes in both sexes; genitourinary diseases in women, and digestive and circulatory diseases in men. Of these common diagnoses mental disorders in women, hazard ratio (95% confidence intervals) 1.24 (1.1–1.4); and mental disorders 1.35 (1.3–1.5), digestive diseases 1.29 (1.1–1.6) and circulatory diseases 1.35 (1.2–1.6) in men were associated with mortality after adjustment for age, employment grade and sickness absence in all other diagnostic categories.
Employees with medically-certified absence spells of one week or more over a three-year period had a 60% excess risk of early death. In women and men, this excess risk was associated with some of the commonest diagnoses of sickness absence, in particular mental disorders. Sickness absence for mental disorders may be a useful early indicator of groups at increased risk of fatal disease.
PMCID: PMC2695575  PMID: 19039005
mortality, sickness absence, cause-specific, mental disorders, digestive diseases, circulatory diseases
12.  Determinants in adolescence for adult sickness absence in women and men: a 26-year follow-up of a prospective population based cohort (Northern Swedish cohort) 
BMC Public Health  2013;13:75.
To date little is known regarding how factors measured in adolescence predict sickness absence in adulthood, and whether different patterns of factors exist for women and men that could contribute to an explanation of adult gender differences in sickness absence.
All pupils in the last year of compulsory school in the municipality of Luleå with complete information from surveys (questionnaires) in 1981 and 1983 (compulsory and upper-secondary schooling; 16 and 18 years of age, N=719) were followed with register data on medically certified sickness absence (1993–2007). Generalised linear models were applied to calculate Risk Ratios with 95% Confidence Intervals (CI) comparing annual mean numbers of sickness absence spells in exposed versus unexposed groups.
In the multivariate model, the following factors were found to be predictive of future sickness absence in women: participating in an upper secondary school program in 1983 dominated by women (> 60%): 1.41 (95% CI 1.00 – 1.97); sometimes sickness absence from school in 1981: 1.60 (95% CI 1.18 – 2.17) and low parental socioeconomic status in 1981: 2.20 (95% CI 1.44 – 3.38). In men, low school grades in 1981: 4.36 (95% CI 2.06 – 9.22) and fathers not in gainful employment in 1981: 2.36 (95% CI 1.53 – 3.66) were predictive.
The findings suggest that sickness absence in adulthood is predicted by factors measured in adolescence. These predictors may differ for women and men. For women, early life absence and social environmental factors, for men low achievements at school and lack of employment of their father seem to be predictive.
PMCID: PMC3566932  PMID: 23351779
Sickness absence; Gender; Socio-economic; Parental
13.  Is There an Association between Long-Term Sick Leave and Disability Pension and Unemployment beyond the Effect of Health Status? – A Cohort Study 
PLoS ONE  2012;7(4):e35614.
Studies have shown that long-term sick leave is a strong predictor of disability pension. However, few have aimed to disentangle the effect of sick leave and of health status.
The objective of this study was to investigate whether there is an association between long-term sick leave and disability pension and unemployment, when taking health status into account.
Methods/Principal Findings
The study was based on the Stockholm Public Health Cohort, restricted to 13,027 employed individuals (45.9% men) aged 18–59 in 2002 and followed until 2007.
Hazard ratios (HR) with 95% Confidence Interval (CI) were estimated by Cox regression models adjusting for socio-demographic factors and five measures of health status.
Having been on long-term sick leave increased the risk of disability pension (HR 4.01; 95% CI 3.19–5.05) and long-term unemployment (HR 1.45; 95% CI 1.05–2.00), after adjustment for health status. The analyses of long-term sick leave due to specific illness showed that the increased risk for long-term unemployment was confined to the group on sick leave due to musculoskeletal (HR 1.70 95% CI 1.00–2.89) and mental illness (HR 1.80 95% CI 1.13–2.88) and further that there was an increased risk for short-term unemployment in the group on sick leave due to mental illness (HR1.57 95%CI 1.09–2.26).
Long-term sick leave increases the risks of both disability pension and unemployment even when taking health status into account. The results support the hypothesis that long-term sick leave may start a process of marginalization from the labor market.
PMCID: PMC3338415  PMID: 22558176
14.  Promoting work ability in a structured national rehabilitation program in patients with musculoskeletal disorders: outcomes and predictors in a prospective cohort study 
Musculoskeletal disorders (MSDs) are a major reason for impaired work productivity and sick leave. In 2009, a national rehabilitation program was introduced in Sweden to promote work ability, and patients with MSDs were offered multimodal rehabilitation. The aim of this study was to analyse the effect of this program on health related quality of life, function, sick leave and work ability.
We conducted a prospective, observational cohort study including 406 patients with MSDs attending multimodal rehabilitation. Changes over time and differences between groups were analysed concerning function, health related quality of life, work ability and sick leave. Regression analyses were used to study the outcome variables health related quality of life (measured with EQ-5D), and sick leave.
Functional ability and health related quality of life improved after rehabilitation. Patients with no sick leave/disability pension the year before rehabilitation, improved health related quality of life more than patients with sick leave/disability pension the year before rehabilitation (p = 0.044). During a period of −/+ four months from rehabilitation start, patients with EQ-5D ≥ 0.5 at rehabilitation start, reduced their net sick leave days with 0.5 days and patients with EQ-5D <0.5 at rehabilitation start, increased net sick leave days with 1.5 days (p = 0.019). Factors negatively associated with sick leave at follow-up were earlier episodes of sick leave/disability pension, problems with exercise tolerance functions and mobility after rehabilitation. Higher age was associated with not being on sick leave at follow-up and reaching an EQ-5D ≥ 0.5 at follow-up. Severe pain after rehabilitation, problems with exercise tolerance functions, born outside of Sweden and full-time sick leave/disability pension the year before rehabilitation were all associated with an EQ-5D level < 0.5 at follow-up.
Patients with MSDs participating in a national work promoting rehabilitation program significantly improved their health related quality of life and functional ability, especially those with no sick leave. This shows that vocational rehabilitation programs in a primary health care setting are effective. The findings of this study can also be valuable for more appropriate patient selection for rehabilitation programs for MSDs.
PMCID: PMC3626929  PMID: 23384339
Sick leave; Musculoskeletal pain; Multimodal rehabilitation; Health related quality of life; Function
15.  Sickness absence and disability pension due to otoaudiological diagnoses: risk of premature death – a nationwide prospective cohort study 
BMC Public Health  2014;14:137.
It is estimated that hearing difficulties will be one of the top ten leading burdens of disease by 2030. Knowledge of mortality among individuals on sick leave or disability pension due to hearing diagnoses is virtually non-existent. We aimed prospectively to examine the associations of diagnosis-specific sick leave and disability pension due to different otoaudiological diagnoses with risks of all-cause and cause-specific mortality.
A cohort, based on Swedish registry data, including all 5 248 672 individuals living in Sweden in 2005, aged 20–64, and not on old-age pension, was followed through 2010. Otoaudiological diagnoses were placed in the following categories: otological, hearing, vertigo, and tinnitus. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox proportional hazard models; individuals on sick leave or disability pension due to different otoaudiological diagnoses during 2005 were compared with those not on sick leave or disability pension.
In multivariable models, individuals with sickness absence due to otoaudiological diagnoses showed a lower risk of mortality, while individuals on disability pension due to otoaudiological diagnoses showed a 14% (95% CI 1-29%) increased risk of mortality, compared with individuals not on sick leave or disability pension. The risk increase among individuals on disability pension was largely attributable to otological (HR 1.56; 95% CI = 1.04-2.33) and hearing diagnoses (HR 1.20; 95% CI = 1.00-1.43).
This large nationwide population-based cohort study suggests an increased risk of mortality among individuals on disability pension due to otoaudiological diagnoses.
PMCID: PMC3922186  PMID: 24507477
Hearing diagnoses; Sick-leave; Mortality
16.  Co-morbidities increase the risk of disability pension among MS patients: a population-based nationwide cohort study 
BMC Neurology  2014;14:117.
Multiple sclerosis (MS) is a chronic and often disabling disease. In 2005, 62% of the MS patients in Sweden aged 16–65 years were on disability pension. The objective of this study is to investigate whether the presence of common co-morbidities increase MS patients’ risk for disability pension.
This population-based cohort study included 4 519 MS patients and 4 972 174 non-MS patients who in 2005 were aged 17–64 years, lived in Sweden, and were not on disability pension. Patients with MS were identified in the nationwide in- and outpatient registers, while four different registers were used to construct three sets of measures of musculoskeletal, mental, and cardiovascular disorders. Time-dependent proportional hazard models with a five-year follow up were performed, adjusting for socio-demographic factors.
All studied disorders were elevated among MS patients, regardless of type of measure used. MS patients with mental disorders had a higher risk for disability pension than MS patients with no such co-morbidities. Moreover, mental disorders had a synergistic influence on MS patients’ risk for disability pension. These findings were also confirmed when conducting sensitivity analyses. Musculoskeletal disorders appeared to increase MS patients’ risk for disability pension. The results with regard to musculoskeletal disorders’ synergistic influence on disability pension were however inconclusive. Cardiovascular co-morbidity had no significant influence on MS-patients’ risk for disability pension.
Co-morbidities, especially mental disorders, significantly contribute to MS patients’ risk of disability pension, a finding of relevance for MS management and treatment.
PMCID: PMC4055212  PMID: 24894415
Multiple sclerosis; Co-morbidity; Disability pension; Sick leave; Synergistic effects; Insurance medicine
17.  Increased absence due to sickness among employees with fibromyalgia 
Little is known about the effect of fibromyalgia on absence due to sickness in working populations.
To examine the risk of absence due to sickness among employees with fibromyalgia.
A prospective cohort study with 1‐year follow‐up of recorded and certified absence due to sickness after a survey of chronic diseases among 34 100 Finnish public sector employees (27 360 women and 6740 men) aged 17–65 years at baseline in 2000–2.
20 224 days of absence due to sickness for the 644 employees with fibromyalgia and 454 816 days for others were documented. Of those with fibromyalgia, 67% had co‐occurring chronic conditions such as osteoarthritis, rheumatoid arthritis, depression or other psychiatric disorders. Compared with employees with none of these chronic conditions, the hazard ratio (HR) adjusted for age, sex and occupational status was 1.85‐fold (95% confidence interval (CI) 1.53 to 2.18) for people with fibromyalgia alone and 2.63‐fold (95% CI 2.34 to 2.96) for employees with fibromyalgia with coexisting conditions. The excess rate of absence due to sickness was 61 episodes/100 person‐years among people with fibromyalgia alone. Among employees with musculoskeletal and psychiatric disorders, secondary fibromyalgia was associated with a 1.4–1.5‐fold increase in risk of absence.
Fibromyalgia is associated with a substantially increased risk of medically certified absence due to sickness that is not accounted for by coexisting osteoarthritis, rheumatoid arthritis or psychiatric disorders.
PMCID: PMC1798407  PMID: 16793839
18.  Work and health among immigrants and native Swedes 1990–2008: a register-based study on hospitalization for common potentially work-related disorders, disability pension and mortality 
BMC Public Health  2012;12:845.
There are many immigrants in the Swedish workforce, but knowledge of their general and work-related health is limited. The aim of this register-based study was to explore whether documented migrant residents in Sweden have a different health status regarding receipt of a disability pension, mortality and hospitalization for lung, heart, psychiatric, and musculoskeletal disorders compared with the native population, and if there were variations in relation to sex, geographical origin, position on the labor market, and time since first immigration.
This study included migrants to Sweden since 1960 who were 28–47 years old in 1990, and included 243 860 individuals. The comparison group comprised a random sample of 859 653 native Swedes. These cohorts were followed from 1991 to 2008 in national registers. The immigrants were divided into four groups based on geographic origin. Hazard ratios for men and women from different geographic origins and with different employment status were analyzed separately for the six outcomes, with adjustment for age, education level, and income. The influence of length of residence in Sweden was analyzed separately.
Nordic immigrants had increased risks for all investigated outcomes while most other groups had equal or lower risks for those outcomes than the Swedes. The lowest HRs were found in the EU 15+ group (from western Europe, North America, Australia and New Zealand). All groups, except Nordic immigrants, had lower risk of mortality, but all had higher risk of disability pension receipt compared with native Swedes. Unemployed non-Nordic men displayed equal or lower HRs for most outcomes, except disability pension receipt, compared with unemployed Swedish men. A longer time since first immigration improved the health status of men, while women showed opposite results.
Employment status and length of residence are important factors for health. The contradictory results of low mortality and high disability pension risks need more attention. There is great potential to increase the knowledge in this field in Sweden, because of the high quality registers.
PMCID: PMC3532317  PMID: 23039821
Immigrant; Migration; Health; Hospitalization; Disability pension; Mortality; Labor market; Employment; Unemployment; Sweden
19.  Work–family conflict as a risk factor for sickness absence 
(1) To study both cross‐sectional and prospective relationships between work–family conflict and sickness absence from work; (2) to explore the direction of the relationships between the different types of conflict (work–home interference and home–work interference) and sickness absence; and (3) to explore gender differences in the above relationships.
Data from the Maastricht Cohort Study were used with six months of follow up (5072 men and 1015 women at T6). Work–family conflict was measured with the Survey Work–Home Interference Nijmegen (SWING). Sickness absence was assessed objectively through individual record linkage with the company registers on sickness absence.
In the cross‐sectional analyses, high levels of work–family conflict, work–home interference, and home–work interference were all associated with a higher odds of being absent at the time of completing the questionnaire, after controlling for age and long term disease. Differences in average number of absent days between cases and non‐cases of work–home interference were significant for men and most pronounced in women, where the average number of absent days over six months follow up was almost four days higher in women with high versus low–medium work–home interference.
A clear relation between work–family conflict and sickness absence was shown. Additionally, the direction of work–family conflict was associated with a different sickness absence pattern. Sickness absence should be added to the list of adverse outcomes for employees struggling to combine their work and family life.
PMCID: PMC2092520  PMID: 16698806
work–home interference; home–work interference; sick leave; cohort study
20.  Sickness absence as a global measure of health: evidence from mortality in the Whitehall II prospective cohort study 
BMJ : British Medical Journal  2003;327(7411):364.
Objective To examine the association between sickness absence and mortality compared with associations between established health indicators and mortality.
Design Prospective cohort study. Medical examination and questionnaire survey conducted in 1985-8; sickness absence records covered the period 1985-98.
Setting 20 civil service departments in London.
Participants 6895 male and 3413 female civil servants aged 35-55 years.
Main outcome measure All cause mortality until the end of 1999.
Results After adjustment for age and grade, men and women who had more than five medically certified absences (spells > 7 days) per 10 years had a mortality 4.8 (95% confidence interval 3.3 to 6.9) and 2.7 (1.5 to 4.9) times greater than those with no such absence. Poor self rated health, presence of longstanding illness, and a measure of common clinical conditions comprising diabetes, diagnosed heart disease, abnormalities on electrocardiogram, hypertension, and respiratory illness were all associated with mortality—relative rates between 1.3 and 1.9. In a multivariate model including all the above health indicators and additional health risk factors, medically certified sickness absence remained a significant predictor of mortality. No linear association existed between self certified absence (spells 1-7 days) and mortality, but the findings suggest that a small amount of self certified absence is protective.
Conclusion Evidence linking sickness absence to mortality indicates that routinely collected sickness absence data could be used as a global measure of health differentials between employees. However, such approaches should focus on medically certified (or long term) absences rather than self certified absences.
PMCID: PMC175810  PMID: 12919985
21.  Sick leave patterns in common musculoskeletal disorders – a study of doctor prescribed sick leave 
Comparative data on sick leave within musculoskeletal disorders (MSDs) is limited. Our objective was to give a descriptive overview of sick leave patterns in different MSDs.
Using electronic medical records, we collected information on dates and diagnostic codes for all available sick leave certificates, during 2 years (2009–2010), in the North Western part of the Skåne region in Sweden (22 public primary health care centres and two general hospitals). Using the International Classification of Diseases (ICD) 10 codes on the certificates we studied duration, age and sex distribution and recurrent periods of sick leave for six strategically chosen MSDs; low back pain (M54) disc disorders (M51), knee osteoarthritis (M17) hip osteoarthritis (M16) rheumatoid arthritis (M05-M06) and myalgia (M79).
All together 20 251 sick leave periods were issued for 16 673 individuals 16–64 years of age (53% women). Out of the selected disorders, low back pain and myalgia had the shortest sick leave periods, with a mean of 26 and 27 days, respectively, while disc disorders and rheumatoid arthritis had the longest periods with a mean of 150 and 147 days. For low back pain and myalgia 27% and 26% of all sick leave was short (8–14 days) and only 11% and 13%, were long (≥90 days). For the other selected MSDs, less than 5% of the periods were short. For disc disorders, hip osteoarthritis and rheumatoid arthritis, more than 60% of the periods were long (p > 0.001). For back disorders and myalgia most periods were issued in the age groups between 40–49, with similar patterns for women and men. Osteoarthritis and rheumatoid arthritis had most periods in the age groups of 50–64, and patterns for women and men differed. Low back pain, rheumatoid arthritis and myalgia had the greatest share of recurrent sick leave (31%, 34% and 32% respectively).
Duration, age and sex distribution and numbers of recurrent sick leave varies considerably between different MSDs. This underscores the importance of using specified diagnosis, in sick leave research as well as in planning of treatment and rehabilitation and evaluation of prognosis.
PMCID: PMC4060756  PMID: 24886568
Sick leave; Musculoskeletal; Duration of sick leave; Diagnosis; Back pain; Osteoarthritis; Rheumatoid arthritis; Myalgia
22.  Sickness absence in the Whitehall II study, London: the role of social support and material problems. 
STUDY OBJECTIVE--To investigate the role of social supports, social networks, and chronic stressors: (i) as predictors of sickness absence; and (ii) as potential explanations for the socioeconomic gradient in sickness absence. DESIGN--A prospective cohort study (Whitehall II study) with sociodemographic factors, health and social support measured at baseline, and spells of sickness absence measured prospectively. SETTING--Twenty London based non-industrial departments of the British civil service. PARTICIPANTS--Participants were civil servants (n = 10,308), aged 35-55 years at baseline, of whom 67% (6895) were men and 33% (3413) were women. The overall response rate for Whitehall II was 73% (74% for men and 71% for women). The analysis is based on 41% of the sample who had data on reasons for sickness absence and were administered all social support questions. Only 4.3% of participants did not complete all necessary questions and were excluded. MEASUREMENTS AND MAIN RESULTS--High levels of confiding/emotional support from the "closest person" predicted higher levels of both short and long spells of sickness absence. After adjusting for baseline physical and psychological health the effects were increased, suggesting that high levels of confiding/emotional support may encourage illness behaviour rather than generate illness. Social network measures showed a consistent but less striking pattern. Increased levels of negative aspects of social support resulted in higher rates of sickness absence. Material problems strongly predicted sickness absence, but the effect was diminished once adjustment for the covariables was made, suggesting that health status may be functioning as an intervening variable between chronic stressors and sickness absence. In addition, social support may buffer the effects of chronic stressors. Social support did not contribute to explaining the gradient in sickness absence by employment grade beyond that explained by the baseline covariables. CONCLUSIONS--Sickness absence from work is a complex phenomenon, combining illness and coping behaviours. High levels of confiding/emotional support, although not entirely consistent across samples, may either encourage people to stay at home when they are ill or may be accompanied by more social obligations at home prolonging sickness absence. Negative aspects of close relationships may jeopardize health and hence increase sickness absence.
PMCID: PMC1060150  PMID: 7499989
23.  Prognostic factors for disability claim duration due to musculoskeletal symptoms among self-employed persons 
BMC Public Health  2011;11:945.
Employees and self-employed persons have, among others, different personal characteristics and different working conditions, which may influence the prognosis of sick leave and the duration of a disability claim. The purpose of the current study is to identify prognostic factors for the duration of a disability claim due to non-specific musculoskeletal disorders (MSD) among self-employed persons in the Netherlands.
The study population consisted of 276 self-employed persons, who all had a disability claim episode due to MSD with at least 75% work disability. The study was a cohort study with a follow-up period of 12 months. At baseline, participants filled in a questionnaire with possible individual, work-related and disease-related prognostic factors.
The following prognostic factors significantly increased claim duration: age > 40 years (Hazard Ratio 0.54), no similar symptoms in the past (HR 0.46), having long-lasting symptoms of more than six months (HR 0.60), self-predicted return to work within more than one month or never (HR 0.24) and job dissatisfaction (HR 0.54).
The prognostic factors we found indicate that for self-employed persons, the duration of a disability claim not only depends on the (history of) impairment of the insured, but also on age, self-predicted return to work and job satisfaction.
PMCID: PMC3293101  PMID: 22192533
Work disability predictors; special worker populations; musculoskeletal problems
24.  Threshold of Musculoskeletal Pain Intensity for Increased Risk of Long-Term Sickness Absence among Female Healthcare Workers in Eldercare 
PLoS ONE  2012;7(7):e41287.
Musculoskeletal disorders increase the risk for absenteeism and work disability. However, the threshold when musculoskeletal pain intensity significantly increases the risk of sickness absence among different occupations is unknown. This study estimates the risk for long-term sickness absence (LTSA) from different pain intensities in the low back, neck/shoulder and knees among female healthcare workers in eldercare.
Prospective cohort study among 8,732 Danish female healthcare workers responding to a questionnaire in 2004–2005, and subsequently followed for one year in a national register of social transfer payments (DREAM). Using Cox regression hazard ratio (HR) analysis we modeled risk estimates of pain intensities on a scale from 0–9 (reference 0, where 0 is no pain and 9 is worst imaginable pain) in the low back, neck/shoulders and knees during the last three months for onset of LTSA (receiving sickness absence compensation for at least eight consecutive weeks) during one-year follow-up.
During follow-up, the 12-month prevalence of LTSA was 6.3%. With adjustment for age, BMI, smoking and leisure physical activity, the thresholds of pain intensities significantly increasing risk of LTSA for the low back (HR 1.44 [95%CI 1.07–1.93]), neck/shoulders (HR 1.47 [95%CI 1.10–1.96]) and knees (HR 1.43 [95%CI 1.06–1.93]) were 5, 4 and 3 (scale 0–9), respectively, referencing pain intensity of 0.
The threshold of pain intensity significantly increasing the risk for LTSA among female healthcare workers varies across body regions, with knee pain having the lowest threshold. This knowledge may be used in the prevention of LTSA among health care workers.
PMCID: PMC3401109  PMID: 22911772
25.  Low back pain and widespread pain predict sickness absence among industrial workers 
The prevalence of musculoskeletal disorders (MSD) in the aluminium industry is high, and there is a considerable work-related fraction. More knowledge about the predictors of sickness absence from MSD in this industry will be valuable in determining strategies for prevention. The aim of this study was to analyse the relative impact of body parts, psychosocial and individual factors as predictors for short- and long-term sickness absence from MSD among industrial workers.
A follow-up study was conducted among all the workers at eight aluminium plants in Norway. A questionnaire was completed by 5654 workers at baseline in 1998. A total of 3320 of these participated in the follow-up study in 2000. Cox regression analysis was applied to investigate the relative impact of MSD in various parts of the body and of psychosocial and individual factors reported in 1998 on short-term and long-term sickness absence from MSD reported in 2000.
MSD accounted for 45% of all working days lost the year prior to follow-up in 2000. Blue-collar workers had significantly higher risk than white-collar workers for both short- and long-term sickness absence from MSD (long-term sickness absence: RR = 3.04, 95% CI 2.08–4.45). Widespread and low back pain in 1998 significantly predicted both short- and long-term sickness absence in 2000. In addition, shoulder pain predicted long-term sickness absence. Low social support predicted short-term sickness absence (RR = 1.28, 95% CI 1.11–1.49).
Reducing sickness absence from MSD among industrial workers requires focusing on the working conditions of blue-collar workers and risk factors for low back pain and widespread pain. Increasing social support in the work environment may have effects in reducing short-term sickness absence from MSD.
PMCID: PMC200978  PMID: 12956891
sickness absence; musculoskeletal disorders; low back pain; widespread pain; blue-collar workers; social support

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