SELF-RATED HEALTH AND RETURN TO WORK AFTER FIRST-TIME STROKE

Transcription

1 J Rehbil Med 2016; 48: ORIGINAL REPORT SELF-RATED HEALTH AND RETURN TO WORK AFTER FIRST-TIME STROKE Louise Ppe Lrsen, MPH 1,2, Krin Biering, MPH, PhD 3, Soeren Pske Johnsen, MD, PhD 4, Grethe Andersen, MD, DMSc 5 nd Niels Henrik Hjollund, MD, PhD 1,4 From the 1 AmbuFlex/WestChronic, Regionl Hospitl West Jutlnd, Herning, 2 Deprtment of Clinicl Medicine, Fculty of Helth Sciences, Arhus University, Arhus, 3 Deprtment of Occuptionl Medicine, Regionl Hospitl West Jutlnd, Herning, 4 Deprtment of Clinicl Epidemiology nd 5 Deprtment of Neurology, Arhus University Hospitl, Arhus, Denmrk Objective: Self-rted helth is n essentil spect of life fter stroke, nd return to work is considered one of the most importnt outcomes for younger stroke ptients. The im of this study ws to exmine whether self-rted helth 3 months fter stroke, clinicl nd demogrphic determinnts re independently ssocited with return to work nd subsequent work-stbility. Mteril nd methods: A totl of 590 ptients with firsttime stroke were included from Dnish popultion-bsed cohort study. All ptients were younger thn 60 yers nd working or unemployed t the time of stroke. Informtion on self-rted helth (Short Form 12; SF-12) ws collected from questionnires 3 months fter stroke. Employment sttus ws defined on weekly bsis using ntionl registerdt on trnsfer pyments. Results: Fifty percent were self-supporting or job-seeking 12 months fter stroke, nd the sme proportion ws found fter 24 months. More thn 70% of the ptients who returned to work did not receive sickness benefits in the 12 months following return to work. Good self-rted helth 3 months fter stroke nd minor stroke severity were strongly ssocited with return to work fter 12 nd 24 months. Conclusion: Self-rted helth 3 months fter stroke ws strongly ssocited with return to work nd work-stbility fter stroke. Key words: cohort studies; qulity of life; return to work; stroke. J Rehbil Med 2016; 48: Correspondence ddress: Louise Ppe Lrsen, AmbuFlex, Regionl Hospitl Jutlnd, Gl. Lndevej 61, DK-7400 Herning, Denmrk. E-mil: nllr@rm.dk Accepted Dec 11, 2015; Epub hed of print Mr 2, 2016 INTRODUCTION In the Scndinvin countries, the incidence of stroke is pproximtely 2 per 1,000 person-yers (1). The mjority of stroke ptients re over 65 yers of ge t the time of stroke nd hve lredy left, or re bout to leve, the lbour mrket. However, pproximtely 20 30% of stroke ptients re younger thn 65 yers, nd substntil prt re eligible for return to work (RTW) (2). Among stroke ptients of working ge, RTW hs been identified s one of the most importnt outcomes in terms of socil functioning, wellbeing nd life stisfction for the ptients (3, 4). In ddition, being employed fcilittes independent living for the ptients nd decreses the finncil burden on society (5, 6). Mny fctors hve been investigted s possible risk fctors for post-stroke ptients bility to RTW, nd severl risk-fctors for RTW fter stroke hve been identified in demogrphic, physicl, clinicl nd socil fields (7, 8). Self-rted helth or helth-relted qulity of life hs been defined by the World Helth Orgniztion (WHO) s n individul s perception of their position in life in the context of the culture nd vlue systems in which they live, nd in reltion to their gols, expecttions, stndrds nd concerns. A self-reported mesure consisting of multiple dimensions tht includes, but is not limited to the concepts of physicl, socil nd emotionl helth (9). This definition emphsizes subjective helth nd embodies the perception nd evlution by ptients themselves of the impct on their lives cused by the disese nd its consequences (10). Self-rted helth hs been reported to be n importnt predictor of the prognosis of stroke ptients (11), but whether or not self-rted helth is lso ssocited with RTW is unknown. Another issue sprsely investigted is the stbility of employment fter returning to work. A Germn study found tht 28% of the ptients who returned to work in mixed popultion (hed injury nd stroke), left the workforce permnently within 2-yer period (12). This suggests tht remining t work my be chllenge for these ptients. Gret vrition hs been found in previous studies describing the proportion of ptients returning to work fter stroke (8). This my be due to different popultions nd mesurements, but lso limited smple sizes in the mjority of studies my be prt of the explntion. The im of this study ws to describe RTW nd the subsequent work-stbility in Dnish popultion-bsed cohort of stroke ptients, nd to exmine whether self-rted helth 3 months fter stroke, clinicl nd demogrphic determinnts re independently ssocited with RTW nd work-stbility The Authors. doi: / Journl Compiltion 2016 Foundtion of Rehbilittion Informtion. ISSN

2 340 L. P. Lrsen et l. MATERIAL AND METHODS Subjects nd study design The study popultion consisted of ptients with first-time stroke, who hd been dmitted to hospitl in the Centrl Denmrk Region between 1 October 2008 nd 31 December Centrl Denmrk Region is one of 5 dministrtive units in Denmrk, with pproximtely 1.2 million inhbitnts (13). During the study period the region ws served by 7 stroke units. All ptients were identified from the Dnish Stroke Register (DSR), which is ntionwide inititive to monitor nd improve the qulity of cre for ptients with cute stroke (14). The study ws nested in lrger cohort study investigting selfreported helth mong first-time stroke ptients. In the min study, ptients younger thn 80 yers, who were live 90 dys fter stroke nd living in their own homes prior to the stroke were included nd invited to prticipte in follow-up study. Three months fter the stroke, short questionnire including questions on self-rted helth (SF-12) ws delivered by post. If the ptients responded, they would receive more comprehensive questionnire 3 months lter nd subsequently every 6 months until 2.5 yers from stroke onset. The follow-up questionnires included items on self-rted helth (SF-12) (15), degree of disbility (WHO, Disbility Assessment Schedule; WHODAS) (16), nxiety nd depression (Hospitl Anxiety nd Depression Scle; HADS) (17), nd eductionl level. Non-respondents were sent new questionnire 3 months lter nd gin 6 months fter the first questionnire if there ws still no response. Since 1968, ll Dnish residents hve been ssigned unique civil registrtion number, which is used in ll helth dtbses nd permits unmbiguous record linkge between dtbses. The Civil Registrtion System contins informtion on civil registry number, nme, gender, ddress, dte of birth nd vitl sttus (18). Informtion on ddress nd vitl sttus ws collected online prior to pproching the individul ptient. In Denmrk, people in the ge rnge yers hve the opportunity to tke erly retirement. All included ptients were 60 yers or younger t time of stroke, nd were either working or unemployed prior to the stroke, mking RTW n option. Working sttus Informtion on weekly employment sttus ws collected from The Dnish Register for Evlution of Mrginlistion (DREAM), which includes informtion on ll public trnsfer pyments dministered by Dnish ministries nd municiplities since In Denmrk, employed citizens re entitled to sick-leve benefit fter 2 weeks of employment, or, if n employer pys their slry during sick leve, the employer receives municipl reimbursement. If there is no trnsfer income registered for specific week, the person is considered to be self-supporting or on short-term sick leve. It ws not possible to detect whether the ptient returned to the sme job nd the sme mount of working hours per week. Ptients were registered s being on sick leve if they received helth-relted benefits, even though they hd begun working prt-time. Dt from the DREAM dtbse hve been compred with other sources of informtion nd found vlid (19, 20). Four outcome vribles were defined: 1. Employment sttus. Employment sttus ws ctegorized into 5 groups (20): 1. Self-supporting (no trnsfer income prt from mternity leve py nd stte eduction fund grnts.). 2. Job-seeking (ptients receiving lbour mrket-relted benefits.). 3. Sick-leve (ptients receiving sickness benefits, voctionl rehbilittion or in flex job (jobs creted for persons with limited work cpcity)). 4. Permnently out of the lbour mrket (ptients on norml or erly retirement. Erly retirement (persons over 60 yers who hve retired voluntrily or who re on n nticiptory pension scheme). 5. Ded Employment sttus ws mesured t 3 specific time-points: 3, 12 nd 24 months fter stroke. 2. Return to work. RTW ws defined s being self-supporting or jobseeking for t lest 4 consecutive weeks from time of stroke nd up to 24 months therefter, nd ws dichotomized into yes/no. Job-seeking ptients receiving lbour mrket-relted benefits were ctegorized s hving returned to work, since such benefits re only grnted if person is ssessed to be redy to work. 3. Work-stbility. A Work Prticiption Score within 12 months following RTW ws clculted s the proportion of the number of weeks t work or s job-seeker in the numertor nd the number of weeks receiving sickness benefits or pension plus the number of RTW weeks in the denomintor (19). The Work Prticiption Score ws ctegorized into 3 groups reflecting the percentges of weeks t work for descriptive use nd dichotomized t 80% in regression nlysis. 4. Trnsitions. Trnsitions were defined s the number of trnsitions between self-supporting or job-seeking nd being on sick leve or retirement during the following 12 months fter RTW. Trnsitions were ctegorized into 3 groups with 0, 1 2 nd 3 or more trnsitions. Self-rted helth The Short Form 12 (SF-12) is generic mesure of self-rted helth tht describes the ptients experiences of function nd well-being in physicl, mentl nd socil dimensions of life during the previous 4 weeks (15). The SF-12 consists of 12 questions tht correspond to 8 subscles nd 2 summry scores (Physicl Component Summry (PCS) nd Mentl Component Summry (MCS)). All of the SF-12 scores re grded from 0 to 100, with higher scores indicting better helth. The summry scores re norm-bsed with men of 50, nd the SD equls 10 in US popultion smple (15). The 8 subscles were ctegorized into 4 groups with cut-offs t 25, 50 nd 75 points on the scle. The summry scores were ctegorized with cut-offs t the 25th, 50th nd 75 th percentiles. The Dnish trnsltion of the stndrd SF-12 version 2.0 ws used, with scoring s suggested by Wre et l. (15, 21). The SF-12 hs shown stisfctory relibility nd vlidity in previous studies of stroke ptients (22 24). Covrites Gender nd ge were identified from the civil registrtion number. Informtion bout mritl sttus, body mss index (BMI), lcohol consumption, smoking, type of stroke nd stroke severity ws obtined from the DSR. Stroke severity t time of dmittnce ws evluted by the Scndinvin Stroke Scle (SSS), which is grded from 0 58, with low scores indicting high severity (25, 26). Eductionl level ws obtined from the questionnire (fter 6 months) nd ctegorized ccording to the Interntionl Stndrd Clssifiction of Eduction (27). If informtion on eductionl level ws missing in the questionnire, register-bsed informtion on trde union membership ws used to estimte this (20). Informtion on co-morbidity ws obtined from the Dnish Ntionl Ptient Registry nd re-coded into the Chrlson Comorbidity Index (28). Aprt from stroke, which ws not included in the clcultion of the index, very few ptients hd more thn 1 co-morbid disese, nd for tht reson the index ws dichotomized t 0/1 in the nlysis. Sttisticl nlysis A correltion nlysis between exposure vribles ws initilly performed, nd no correltion exceeded Adjusted odds rtios (OR) of the ssocition between SF-12, covrites nd RTW fter 12 nd 24 months of follow-up were clculted using multivrible logistic regression. Anlysis of RTW nd SF-12 components were djusted for ge, gender, eductionl level, co-morbidity nd stroke severity. Age, gender, eductionl level, comorbidity nd stroke severity were mutully djusted nd djusted for PCS. Survivl nlysis ws originlly considered the most pproprite nlysis for the im of this study. However, only ptients vilble for RTW (on sick leve) 3 months fter the stroke could be included in this time-to-event nlysis. Hence, the nlysis ws produced to substntite results of the logistic regression. Cox regression ws used to estimte the hzrd rtio (HR) or risk rte rtio for RTW 12 months fter stroke ccording to exposure

3 Self-rted helth nd RTW fter firts-time stroke 341 vribles, tking competing risks (retirement nd deth) into ccount. The HR cn be interpreted s reltive risk. The ssocition between self-rted helth nd the Work Prticiption Score ws lso computed by multivrible logistic regression. Multiple imputtions were used to hndle missing dt. The imputtion model ws bsed on register-bsed dt s well s dt from the questionnires nd took the individul time course into ccount. A totl of 25 dtsets were imputed. All nlysis were performed both with nd without the imputed dt, nd the results compred. Furthermore, sensitivity nlysis, ssuming tht ll missing dt were from ptients with 5 points (0.5 SD) lower or higher self-rted helth thn estimted with the imputtion model, ws crried out. All dt mngement nd sttisticl nlysis were mde using Stt 13.0 SE. RESULTS A totl of 4,327 ptients were identified in the DSR. Of these, 1,106 ptients did not meet the inclusion criteri for the min study (Fig. 1). In ll, 2,225 ptients were older thn 60 yers t the time of stroke, nd 214 received erly retirement benefits before the stroke nd were therefore not ble to RTW. Eight ptients died nd thus did not return the questionnire, nd 184 did not respond, resulting in study popultion of 590 ptients (Fig. 1). During the first 3 months fter stroke, 167 ptients returned to work nd 6 left the workforce due to erly retirement. Thus, 417 ptients were still vilble for RTW when the first mesurement of self-rted helth ws mde 3 months fter the stroke. First-time stroke ptients <80 yers identified in the Dnish Stroke Register, n=4,327 Ptients miled, n=782 Prticipted with one or more returned questionnires, n=590 Fig. 1. Selection of study prticipnts. Ptients excluded in the min study (n=1,106) Died within the first 3 months, n=436 Living in nursing home, n=373 Missing register informtion, n=237 Hidden ddress/emigrted, n=60 Ptients excluded, n=2,439 Age +60 yers, n=2,225 Erly retirement prior to the stroke, n=214 Ptients dying before nswering the first questionnire, n=8 Non-respondents, n=184 Bseline chrcteristics Chrcteristics of the popultion re presented in Tble I. Approximtely two-thirds of the ptients were men, nd hlf of the popultion hd ttined medium eductionl level. Tble I. Ptient chrcteristics t time of stroke nd self-rted helth fter 3 months Chrcteristics All ptients Totl, 590 (100) Gender, Femle 36 Mle 64 Age, 49 yers yers 62 Eduction, Low (< 11 yers) 21 Medium (11 14 yers) 51 High (> 14 yers) 25 Missing 4 Mritl sttus, Mrried/cohbiting 78 Single 21 Missing 1 Stroke severity, Mild 72 Moderte 11 Severe 5 Very severe 5 Missing 7 Dignosis, Intrcerebrl hemorrhge 11 Ischemic 86 Unspecified 3 Comorbidity, Chrlsons index 0 78 Chrlsons index Chrlsons index 3+ 3 Smoking sttus, Current 44 Former 19 Never 32 Missing 4 Alcohol, < 14/21 drinks per week 84 > 14/21 drinks per week 11 Missing 5 Body mss index, < 25 kg/m kg/m 2 34 > 30 kg/m 2 22 Missing 15 SF-12, men (SD) Physicl Component Score (PCS) 44.0 (10.9) Mentl Component Summry (MCS) 44.2 (11.1) Physicl Functioning (PF) 66.4 (32.7) Role Physicl (RP) 53.1 (30.4) Bodily Pin (BP) 73.3 (30.1) Generl Helth (GH) 55.4 (26.4) Vitlity (VT) 40.4 (27.3) Socil Functioning (SF) 74.2 (27.9) Role Emotionl (RE) 61.9 (30.6) Mentl Helth (MH) 63.5 (21.9) SF-12: Short Form 12; SD: stndrd devition.

4 342 L. P. Lrsen et l. The proportion of ptients hving mild stroke ws 72%, nd 86% of the ptients hd hd n ischemic stroke. More thn three-qurters of the popultion did not hve other diseses (Tble I). Non-respondents were slightly younger, more often smokers nd living lone (dt not shown). MH PF RP Employment sttus One yer fter the stroke, 294 ptients (50%) were selfsupporting or job-seeking, 66 (11%) hd left the workforce permnently, nd 230 (39%) were still on sick leve (Tble II). Two yers fter the stroke, 48% were self-supporting or jobseeking, while 36% hd left the workforce permnently nd 16% were on sick leve (Tble II). For ptients still on sick leve 3 months fter the stroke, the proportion of ptients in work or job-seeking ws pproximtely 30% fter 12 nd 24 months, respectively. Among the ptients who returned to work during the first 3 months (n = 167), the proportion of self-supporting or job-seeking ptients fter 12 months ws 91% (Tble II). Self-rted helth nd return to work A high level of self-rted helth 3 months fter stroke ws ssocited with higher odds of being t work 12 nd 24 months fter the stroke for ll components of the SF-12 (Tble III). In ll scles, better self-rted helth ws ssocited with higher chnce of RTW (Fig. 2). The lrgest difference between high nd low self-rted helth ws found in the domins relted to physicl function, e.g. ptients with high scores of physicl function (PF) hd 9 times higher odds of RTW (djusted OR 9.0 (95% confidence intervl; 95% CI ) compred with ptients with low self-rted physicl function. Also in Generl Helth (GH) nd in Role Emotionl (RE), ptients with high scores hd more thn 7 times higher odds of RTW within the first yer. Although the risk estimtes only differed mrginlly from the first to the second yer, there ws stedy trend towrds stronger ssocition between self-rted helth 3 months fter stroke nd being employed fter 2 yers compred with 1 yer fter the stroke (Tble III). For ptients still on sick leve 3 months fter stroke (n = 417), time-to-event nlysis with Cox regression found the sme ptterns in ssocitions with better self-rted helth ssocited RE SF 20 0 VT Fig. 2. Short Form 12 (SF-12) men scores ccording to work sttus fter 12 months. PF: Physicl Functioning; RP: Role Physicl; BP: Bodily Pin; GH; Generl Helth; VT: Vitlity; SF: Socil Functioning; RE: Role Emotionl; MH Mentl Helth. with higher chnce of RTW. Adjusted HR for RTW ws 3.7 (95% CI ) for ptients reporting very high vs. very low self-rted physicl helth (PCS). For MCS the corresponding HR ws 2.4 (95% CI ). Other risk fctors of return to work Gender, ge, eductionl level nd co-morbidity were not significntly ssocited with the chnce of returning to work 1 yer fter stroke. Conversely, ptients who hd experienced mild or moderte stroke hd significntly incresed chnce of RTW fter 1 yer (OR 5.0; 95% CI ) compred with ptients with more severe stroke. This effect decresed to n OR of 3.6 (95% CI ) 2 yers fter the stroke (Tble III). Work prticiption score A totl of 370 ptients experienced 4-week period of RTW during the first 2 yers fter stroke (Tble IV). Among ptients returning to work during the first 3 months fter stroke, 140 GH BP Self supporting Sick leve Permnently out Tble II. Employment sttus 12 nd 24 months fter stroke ccording to study popultion 12 months 24 months N Selfsupporting Job-seeking b Sick-leve c Permnently out d Selfsupporting Job-seeking b Sick-leve c Permnently out d All ptients c (47) 16 (3) 230 (39) 66 (11) 285 (48) 1 (0) 92 (16) 212 (36) On sick leve t 3 months (31) 12 (3) 222 (51) 53 (13) 141 (34) 1 (0) 83 (20) 192 (46) RTW during the first 3 months (89) 4 (2) 8 (5) 7 (4) 144 (87) 0 (0) 9 (5) 14 (8) Self-supporting: Ptients who re employed, receiving eduction fund grnts, mternity leve py nd leve-of-bsence schemes. b Job-seeking: Ptients receiving unemployment benefits. c Sick-leve: Ptients receiving sickness benefits, voctionl rehbilittion nd flex job. d Permnently out of lbour mrket: Ptients receiving norml, nd erly, retirement, including ptients who died during the follow-up (At 12 months n = 3; 24 months n = 10). e All ptients eligible t time of stroke including 6 ptients who retired during the first 3 months. RTW: return to work.

5 Self-rted helth nd RTW fter firts-time stroke 343 Tble III. Adjusted odds rtios (OR) of return to work 12 nd 24 months fter stroke ccording to Short Form 12 (SF-12), demogrphic nd clinicl determinnts Return to work SF-12 components n Totl 590 Mentl Component Summry (MCS) Physicl Component Summry (PCS) Physicl Functioning (PF) Role Physicl (RP) 12 months OR b (95% CI) 24 months OR b (95% CI) Ref Ref ( ) 1.7 ( ) ( ) 2.8 ( ) ( ) 5.6 ( ) Ref Ref ( ) 1.5 ( ) ( ) 2.8 ( ) ( ) 7.1 ( ) Ref Ref ( ) 2.1 ( ) ( ) 3.7 ( ) ( ) 9.3 ( ) Ref Ref ( ) 3.4 ( ) ( ) 5.3 ( ) ( ) 14.5 ( ) Bodily Pin (BP) Ref Ref ( ) 1.2( ) ( ) 2.0 ( ) ( ) 4.0 ( ) Generl Helth (GH) Ref Ref ( ) 2.7 ( ) ( ) 5.8 ( ) ( ) 17.2 ( ) Vitlity (VT) Ref Ref ( ) 2.1 ( ) ( ) 5.4 ( ) ( ) 6.8 ( ) Socil Functioning (SF) Role Emotionl (RE) Mentl Helth (MH) Ref Ref ( ) 1.5 ( ) ( ) 2.3 ( ) ( ) 5.3 ( ) Ref Ref ( ) 2.9 ( ) ( ) 4.6 ( ) ( ) 9.7 ( ) Ref Ref ( ) 1.7 ( ) ( ) 3.0 ( ) ( ) 7.2 ( ) Gender Femle 210 Ref Ref Mle ( ) 1.4 ( ) Age Ref Ref ( ) 1.2 ( ) Eductionl level Low 129 Ref Ref Medium ( ) 1.1 ( ) High ( ) 1.7 ( ) Comorbidity ( ) 1.4 ( ) Ref Ref Stroke severity Moderte/mild ( ) 3.6 ( ) Very severe/severe 66 Ref Ref SF-12 summry scores were ctegorized t the 25, 50 nd 75 th percentiles. The 8 subscles were ctegorized into 4 groups with cut-offs t 25, 50 nd 75 points on the scle. b SF-12 components were djusted for ge, gender, eductionl level, co-morbidity nd stroke severity. Age, gender, eductionl level, comorbidity nd stroke severity were mutully djusted nd djusted for Physicl Component Summry. 95% CI: 95% confidence intervl. Tble IV. Work stbility 12 months fter return to work (RTW) ccording to time of initil RTW Time for RTW fter stroke 0 3 months 3 12 months months Totl (n = 370) 179 (100) 150 (100) 41 (100) Work prticiption score 0 50% 13 (7) 15 (10) 9 (22) % 26 (15) 39 (26) 9 (22) 100% 140 (78) 96 (64) 23 (56) Trnsitions b (rnge 0 10) (82) 110 (73) 29 (71) (15) 31 (21) 8 (20) 3+ 6 (3) 9 (6) 4 (9) Proportion of weeks t work the first 12 months fter RTW. b Trnsitions between self-supporting or job-seeking nd sick leve the succeeding 12 months fter RTW. (78%) ptients did not t ny time receive sickness benefits the following 12 months fter RTW, 26 (15%) worked between 50% nd 99% of the weeks, nd 13 (7%) worked less thn hlf of the time. The proportion of ptients not on sick leve the first yer fter initil RTW decresed to 64% mong ptients returning to work 3 12 months fter the stroke, nd to 56% for ptients returning to work during the second yer fter stroke (Tble IV). High levels of self-rted helth were found to be ssocited with higher Work Prticiption Score (Tble V). Trnsitions The rnge of trnsitions between self-supporting nd being on sick leve ws 0 10 in the first yer following RTW. Regrdless of the time of RTW, in more thn 70% of the ptients there were no trnsition from self-supporting to sick leve in the 12 months following RTW (Tble IV). Tble V. Work stbility fter stroke ccording to Short Form 12 (SF-12) component scores for ptients returning to work during the first yer Work prticiption score Totl (n = 329) Adjusted OR b (95% CI) Mentl Component 0 34 Ref Summry ( ) ( ) ( ) Physicl Component 0 35 Ref Summry ( ) ( ) ( ) SF-12 summry scores were ctegorized t the 25, 50 nd 75 th percentiles. b MCS/PCS were djusted for ge, gender, eductionl level, co-morbidity nd stroke severity. OR: odds rtio: 95% CI: 95% confidence intervl. p

6 344 L. P. Lrsen et l. Missing dt Estimtes were lmost identicl in the complete cse nlysis (dt not shown) nd the presented estimtes bsed on imputed dtsets. A sensitivity nlysis, ssuming tht ll missing dt were from ptients with 5 points lower or higher self-rted helth thn estimted with the imputtion model, showed no difference in risk estimtes for RTW ccording to demogrphic nd stroke-relted fctors, compred with the observed nd imputed dtset (dt not shown). DISCUSSION In this popultion-bsed study of stroke ptients, pproximtely 50% of the ptients were self-supporting or job-seeking 12 months fter the stroke, nd the sme proportion ws found fter 24 months. However, the proportion of ptients leving the lbour mrket permnently incresed during the second yer, nd conversely, the proportion of ptients on sick leve decresed. High levels of self-rted helth 3 months fter stroke were strongly ssocited with RTW fter 12 months. In this study, poor self-rted physicl helth 3 months fter stroke ws the strongest risk-fctor for not returning to work fter 12 months, but ftigue (vitlity), poor generl nd mentl helth, stroke severity nd role limittions due to mentl problems lso highly influenced the odds of RTW. More thn 70% of the ptients who returned to work did not receive ny sickness benefits during the following 12 months, 20% worked between 50% nd 99% of the weeks nd only 8% worked less thn hlf of the weeks. Good self-rted helth ws found to be ssocited with high work stbility fter returning to work. In review by Treger et l. (8) on RTW fter stroke, vrition between 19% nd 73% in RTW ws found when compring the results from 16 different countries. Our results were in ccordnce with previous findings from Denmrk (29), but were lower thn findings in other Scndinvin studies (6, 7). This could prtly be explined by the wy of mesuring nd defining RTW. We used register-bsed dt in contrst to ptientreported dt, nd defined RTW s being self-supporting or job-seeking for t lest 4 weeks in row. It could lso be due to structurl cuses, such s vrious offers of helth-relted benefits nd rehbilittion services. Self-rted physicl helth ws strongly ssocited with RTW within the first yer, with ptients reporting high level of physicl helth hving 7 times higher odds of RTW thn ptients with low rtes of physicl helth 3 months fter stroke. Severl studies hve found impirment in ctivities of dily living to be n importnt determinnt of returning to work mong stroke ptients (8, 30, 31), nd Vestling et l. found tht being ble to wlk ws strongly ssocited with the chnce of RTW fter stroke (5). Depression nd ftigue highly influence mentl helth nd hve lso been found to be negtively ssocited with the chnce of returning to work (8, 29, 32). This is in ccordnce with our findings, with ptients reporting high level of mentl helth hving 4 times higher odds of RTW fter yer compred with ptients with low rtings of mentl helth. Stroke severity is, s in our study, previously found to be consistent nd influencing fctor for RTW (33). Previous studies hve, not surprisingly, found ge over 65 yers to be negtive predictor of RTW; however, there re vrious findings in the ssocition between younger stroke ptients nd RTW (8, 33, 34). No ssocition between ge nd RTW ws found in this study. For tht reson we only included ptients younger thn 60 yers, nd there were no obvious opportunity for retirement for the mjority of ptients. The ssocition between gender nd RTW vries in the literture, but the mjority of studies found no ssocition, s in our study (6, 7, 33). Trygged et l. found n ssocition between eductionl level nd RTW (6). A Dnish study of the ssocition between eduction nd RTW fter long-term periods of sick leve (of ll cuses) cme to the sme conclusion (35). Eductionl level ws not ssocited with RTW in this study. Twelve months is normlly the mximum period of the sick-leve benefit in Denmrk, nd returning to work fter this time could be prompted by economic resons despite possible persisting problems, which my hve reduced the effect of self-rted helth on RTW in our study. In support of this ssumption, we found tht ptients who returned to work more thn one yer fter the stroke were more often bsent owing to illness in the following 12 months. Misclssifiction of RTW my occur for severl resons, for instnce, ptients could hve been clssified s being on sick leve if they received helth-relted benefits even though they hd begun working prt-time. Conversely, ptients could hve been clssified s working if they did not receive ny helthrelted benefits, irrespective of working hours per dy. Ptients who were not working, but who were provided with income by their spouses or lived outside estblished society, my hve been ctegorized s self-supporting. Only 2% of the Dnish popultion between 40 nd 67 yers re without personl income, mking this ltter specultion less of problem (36). The first 2 weeks of sick leve is pid by the employer nd, for this reson, ptients on short-term sick leve (less thn 2 weeks) were clssified s self-supporting in our nlysis. This hs contributed to n underestimtion of the number of weeks of sick leve. Possible bis becuse of this my be differentil in reltion to self-rted helth, since ptients with low selfrted helth re often more bsent from work owing to illness. In broder perspective, RTW is contextul with economic trends, nd this study ws undertken t the time of globl finncil crisis, which presumbly incresed the difficulties of returning to the lbour mrket for those with specil needs or/nd lower working cpcity. The proportion of ptients returning to work my therefore hve been lower thn it would hve been if dt hd been collected during period with stronger economy. However, Andersen et l. found similr results in study undertken t time with historic low rte of unemployment in Denmrk (29). This my indicte reltively open nd inclusive lbour mrket in Denmrk. This study my lso indicte need for exploring whether the rehbilittion services offered, i.e. to ptients who report ftigue, re dequte in reltion to RTW.

7 Self-rted helth nd RTW fter firts-time stroke 345 In conclusion, the mjority of the ptients who returned to work fter stroke were not on sick leve the following yer. However, it ws only 50% of the ptients who were self-supporting or job-seeking yer fter their stroke. Self-rted helth 3 months post-stroke nd stroke severity were found to be strongly ssocited with RTW nd subsequent work-stbility fter stroke. ACKNOWLEDGEMENTS This reserch ws supported by The Helth Foundtion nd Trygfonden nd 2/3 fellowship from the Fculty of Helth, Arhus University, Arhus, Denmrk. REFERENCES 1. Truelsen T, Ekmn M, Boysen G. Cost of stroke in Europe. Eur J Neurol 2005; 12 Suppl 1: Feigin VL, Forouznfr MH, Krishnmurthi R, Mensh GA, Connor M, Bennett DA, et l. Globl nd regionl burden of stroke during : findings from the Globl Burden of Disese Study Lncet 2014; 383: Dniel K, Wolfe CD, Busch MA, McKevitt C. Wht re the socil consequences of stroke for working-ged dults? A systemtic review. 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