Persistent asthma, comorbid conditions and the risk of
work disability: a prospective cohort study
R. Hakola1, P. Kauppi2, T. Leino1, A. Ojajärvi3, J. Pentti1, T. Oksanen1, T. Haahtela2, M. Kivimäki1,4
& J. Vahtera1,5
Centre of Expertise for Work Organizations, the Finnish Institute of Occupational Health, Turku and Helsinki; 2Skin and Allergy Hospital,
Helsinki University Hospital; 3Department of Creating Solutions, The Finnish Institute of Occupational Health, Helsinki, Finland; 4Department
of Epidemiology and Public Health, University College London, London, UK; 5Department of Public Health, University of Turku and Turku
University Hospital, Turku, Finland

To cite this article: Hakola R, Kauppi P, Leino T, Ojajärvi A, Pentti J, Oksanen T, Haahtela T, Kivimäki M, Vahtera J. Persistent asthma, comorbid conditions and
the risk of work disability: a prospective cohort study. Allergy 2011; 66: 1598–1603.

Keywords Abstract
asthma; comorbidity; sickness absence;
work disability.
Background: This study examined whether asthma alone or together with chronic
comorbidity is associated with an increased risk of long-term work disability.
Correspondence Methods: We examined data from 2332 asthmatic and 66 354 nonasthmatic public
Paula Kauppi, Skin and Allergy Hospital, sector employees in Finland who responded to a survey between 1997 and 2004.
Meilahdentie 2, PO Box 160, Meilahdentie Respondents were coded as persistent asthmatics based on the special reimburse-
160, Helsinki, Finland. ment for continuous asthma medication by the Social Insurance Institution. Data
Tel.: +358 9 471 86523 on long-term work disability (sickness absences or disability pensions >90 days)
Fax: +358 9 471 86503 were obtained from national registers. The risk of work disability was examined by
E-mail: Cox proportional hazard models adjusted for age, gender, socioeconomic status,
type of employment contract, and type of employer.
Accepted for publication 5 September 2011 Results: Asthma increased the risk of all-cause long-term work disability with haz-
ard ratio (HR) 1.8 (95% CI 1.62–2.09) compared with controls (no asthma).
DOI:10.1111/j.1398-9995.2011.02729.x Asthma and one other chronic comorbidity increased the risk of long-term all-cause
work disability with HR 2.2 (95% CI 1.78–2.83). Asthma together with two or more
Edited by: Michael Wechsler other chronic conditions increased the risk with HR 4.5 (95% CI 2.98–6.78).
Asthma and depression increased the risk with HR 3.6, and the risk was especially
high for permanent work disability (HR 6.8). Among those with asthma, there were
more women, obese individuals (BMI ‡30), ex-smokers, and lower-grade nonmanual
Conclusions: Asthma is associated with an increased risk of long-term all-cause
work disability. The risk increases further with chronic comorbidities and is espe-
cially high in patients with asthma and depression.

Asthma is a common chronic inflammatory disease of the air- Occupational disability can take many forms, including
ways characterized by variable and recurring symptoms, decreased labor force participation rates, change of job or
reversible airflow obstruction, and bronchial hyper-reactivity. job responsibilities because of health reasons, lost work days,
It may decrease the quality of life and is associated with or decreased effectiveness on the job because of illness (5, 8,
adverse behavioral and psychosocial effects (1). Although 9). Previous studies suggest that asthma negatively affects
direct costs related to asthma in terms of physician consulta- work productivity (10–13). Those with asthma are also less
tion and medical treatment are substantial (2, 3), it is now likely to be employed in the first place. We have previously
clear that indirect costs are a great part of total costs in shown that asthma and rhinitis and both these conditions
asthma (4). For example, asthma is one of the leading non- combined increased the risk of short-term sickness absences
musculoskeletal causes of work limitations and has major (12). In a Swedish study, the mean productivity loss was esti-
quality-of-life and economic impacts through occupational mated to be 5.1 days as a result of both allergic rhinitis and
disability (5–7). common cold in the working population (13).

1598 Allergy 66 (2011) 1598–1603 ª 2011 John Wiley & Sons A/S

In Finland. and the linkage was successful for all participants. and provides at present basic date a disability pension was granted between January 1 of reimbursement of 42% for all filled prescriptions and special the year following the survey (1997–1998. diabetes mellitus. we linked the par- ticipants to their records in national health and pension regis. to special reimbursement for asthma medication by the Social We obtained information on the dates of all granted disabil- Insurance Institution in the beginning of the follow-up. A weak association the study. For the follow-up. tal burden of diseases. or reimbursement of 72% or 100% for many chronic and 2004) and 31 December 2005. Six main disease categories were used in this study as comor- Health-related work disability has been increasingly recog. including asthma. socioeco- reversibility of bronchial obstruction or moderate to severe nomic status. the patient’s lung function examination should meet criteria for Sociodemographic characteristics included age. Using personal identification Assessment of long-term all-cause work disability codes assigned to all residents in Finland. kept by the SII of Finland. Of them. All permanent residents aged 16–67 years in Finland are scription Registers maintained by the Social Insurance entitled to daily allowances owing to a sick leave based on a Institution of Finland (SII) and from the Finnish Cancer medical certificate after a waiting period of 9 days. 90 days.or part-time). Thus. obtained from the Finnish Centre for Pensions. tion. In this study. sex. ment for disease medication by the Social Insurance Institu- cause work disability. The linkage was 100% complete with practically no loss absences (‡90 days) and disability pension (permanent or to follow-up. obstructive pulmonary disease and they were excluded from esophageal reflux disease is well known. Work disability included all-cause long-term sickness ters. and/or 2004 (74% of the eligible population (yes or no). tes. ischemic heart disease. This information ees who were employed in the target organization for at least was used to identify those asthma cases who had one comor- 6 months in any year between 1991 and 2005. pension (all long-term work disability) and separately the age. We identified the date of the retired or died before the follow-up began. ditions was derived from the Drug Reimbursement and Pre. entitlements of special reimbursements from the Drug Reim- bursement Register. the final beginning of all sickness absences that lasted longer than cohort comprised 68 686 employees. To be eligi- Other predictors of work disability ble to special reimbursement for asthma medication. Data on disability pension were Finnish Institute of Occupational Health. rheumatic disease. The pension data were available for all participants. bidity or at least two comorbidities from those with no com- 70 376 participants responded to a survey in 1997–1998. we evaluated whether Respondents were coded as positive for diagnosed disease asthma alone or together with comorbidities in general and (other than cancer or depression) based on the reimburse- specifically with depression increases the risk of long-term all. ity pensions. Asthma and long-term work disability Association of asthma with allergic rhinitis and gastro. Data on long-term sickness absences were obtained The study was approved by the ethics committee of the from the SII of Finland.Hakola et al. SES was identified for the study. the national sickness insurance scheme covers occurrence of any long-term sickness absence or disability all permanent residents of the country. The cohort consisted of 151 618 employ. 16). in addi- Registry. Assessment of comorbidities the role of the comorbidity in asthma has rarely been taken into consideration in sickness absence studies (12). disability pension Assessment of asthma can be granted after 300 reimbursed sickness absence days. Respondents were coded as asthmatics if they were entitled This disability pension can be either fixed-term or permanent. bronchial hyper-responsiveness and be confirmed by both and socioeconomic status (SES) of the employees was the patient’s physician and the SII. cancer. diabe- nized as an important component of the economic and socie. sex. Information on asthma and other chronic con. Individuals diagnosed This study is a part of the Finnish Public Sector Study of with cancer during the five preceding years before the follow- public sector employees in 10 towns and 21 public hospitals up were identified from the Finnish Cancer Registry that in Finland (15. full. and marital status. bidity for asthma: depression. separately. orbidities and. responded at least once). regardless of sex. and hypertension. We extracted data on employment status or workplace at follow-up. or occupational title. we noted the date of the first In Finland. and osteoporosis (14). 2000–2002. those cases who had depression 2000–2002. 20 individuals with reimbursement categorized according to the occupational-title classification for asthma medication underwent diagnosis of chronic of the ‘Statistics Finland’ for upper-grade nonmanual work- Allergy 66 (2011) 1598–1603 ª 2011 John Wiley & Sons A/S 1599 . irrespective of participants’ severe diseases. However. of asthma has also been reported with hyperlipidemia. Information on age. for a period of 1 year at the a long-term work disability during the survey year or had most from the SII of Finland.4%) participants who were on tion to the first day of illness. the ear- liest was used in the analyses. Among the asthma cases obtained from the employer-maintained records. compiles all cancer notifications in Finland. depression. Cases of depression were determined from the Drug Prescription Register as those who had purchased more than 30 defined daily dosages (DDDs) of antidepressants (ATC Material and methods code N06A) during the survey year. In case of repeat responses. We excluded 1690 (2. temporary.

Analyses depression alone.0056 smokers. The risk was 1.3).0) (Table 4). the calculated the hazard ratios for those with asthma alone. A large The risk of long-term all-cause work disability increased sample size provides statistical power to detect small differ- with the number of comorbidities.g.7 24..6) 6977 (10. The haz. and chronic conditions increased the risk by 4.2–9.5.. NC. In the group of asthma. large sample size.8) 13 400 (20.0001 was dichotomized to indicate obese (‡30) or nonobese (<30). 95% CI 3.2) 32 757 (49. The study those with asthma further increased the risk of long-term all- groups did not differ in respect of marital status. Asthma together with two or more other vals.6-fold.7 0. Results Discussion Baseline characteristics of the employees with asthma (n = 2332) and those without asthma (n = 66 354) are In this large register-based study of Finnish public sector shown in Table 1. Inc. or 31 December Socioeconomic class 2005.2) <0.6–5.1) 22 690 (34.0012 those without asthma. version 9. of asthma workers (e. For disability pension.3).2 (SAS Institute. and asthma in combination with depression examining depression as a sole comorbid condition showed compared with those with neither of these conditions.8) Respondents reported whether they were nonsmokers. Finally. asthma increased the risk of long-term all-cause women.4) from the 1st January immediately after the year of the survey Current smoker 390 (17.7–2.5-fold (HR 4. these without either of the diseases.6) smoking. Cox proportional hazard models Upper-grade 552 (23. In higher risk when compared with public-sector employees analyses restricted to disability pension as an outcome. had 3.2-fold high precision as indicated by the narrow confidence inter- (95% CI 1.5 times higher risk of work disabil- were adjusted for age.1 (95% CI 1.7) 10 907 (16.8) 19 289 (29. n (%) n (%) P-value Standard survey questionnaires were used to assess infor- mation regarding marital status. 2. USA).6 times higher risk and those with two or more other ability 1. For all-cause disability pension. obese individuals work disability (‡90 days) nearly 2-fold when compared with (BMI ‡30).9) 34 602 (52.4) 0. £44 1101 (47. Cary. and smoking at the beginning of the follow-up. Manual workers 381 (16. lower-grade nonmanual Table 1 Characteristics of study population workers (e. persons with psychological distress.1 <0.8-fold. and obesity.33 (sickness absence >90 days or disability pension).7 + 9.g.4) 57 826 (89.1) 15 891 (24.1 + 9. In addition.8. hazard ratios were 2.. death. response rate are important strengths of this study. respectively. In the present study.7 (95% CI 1.2) 0. Follow-up for work disability began Ex-smoker 883 (39.2) 22 731 (35.. risk was even higher (HR 5.2) 52 954 (79.8) (Table 3).55–1. Lower-grade 1391 (59. employees without asthma.Asthma and long-term work disability Hakola et al.95) when the results were those with persistent asthma and depression had 6.1) when the results chronic conditions had 4. In this analysis.8 + 4. mean ± SD) 44.5.5) and 1.6–2. socioeconomic status.0001 were used to calculate the risk of long-term work disability nonmanual workers and the 95% confidence intervals (CI) for asthmatic partici.6) 29 728 (46. that asthma in combination with depression increased the All analyses were performed using the SAS statistical soft. and manual Asthma No. ers (e. risk of long-term all-cause work disability 3.9 + 4. cause work disability.8) 49 693 (75.1) <0. The data for the outcome as well as asthma and comor- 1600 Allergy 66 (2011) 1598–1603 ª 2011 John Wiley & Sons A/S . smoking. 95% CI 1. Asthmatic employees with depression Asthma increased the risk of long-term all-cause work dis. whichever came first.0–6.012 45–54 796 (34. adjusted hazard ratios were calculated for asthma alone.0001 Chi-square test was used to analyze the differences in fre. physicians and teachers). body mass index (BMI. age. and high 1.2) <0.3) 11 778 (18. gender. the corresponding risk was 6. hazard ratios were large and risk of work disability 1. technicians and registered nurses).6-fold (95% CI ware. Female 1987 (85.8) dent’s t-test of continuous variables in those with asthma and Smoking Nonsmoker 982 (43. cleaners and maintenance workers). asthma and two or more chronic comorbidities. ex.8–2.8-fold (HR 1. kg/ Gender m2). BMI Male 345 (14. we 95% CI 3. Comorbid conditions among and lower-grade nonmanual workers (Table 1).3) response and ended to the occurrence of the work disability Not married 579 (25. and they were estimated with relatively another chronic comorbidity increased this risk by 2. Asthma accompanied with clinically significant. nonmanual workers ard ratios were adjusted for sex.9 (95% CI Prospective study design. SES. ‡30 378 (16. there were more employees. <30 1896 (83.8).3) 0. ity than healthy employees.8 times also adjusted for the presence of comorbidities (Table 2).4) 12 328 (18.4) Statistical analysis BMI (mean ± SD) 25. older employees (55–63 years).6–2.0001 quency distribution of categorical baseline variables and Stu. Age (years.3) pants compared with participants without asthma.g. obesity and for the presence of comorbidities. asthma and one chronic comorbidity.7 44. official Married 1726 (74. similarly.8) retirement pension (old-age pension). or current smokers. asthma ences and reduces the likelihood of random error influencing without any other chronic comorbid condition increased the the results. ex-smokers. For disability pension only.2) 55–63 435 (18.

2.55.) mechanisms for dealing with chronic disease and their atti- Asthma.55 (1. to have short-term rather than long-term work-disability peri- ods.98. The study population comprised public Asthma alone 1787 213 1. 2.87) sector employees and may not be generalized into unselected Asthma + 1 chronic 347 74 2. no depression 2042 273 1. these results show that hazard ratios (HR) and 95% confidence intervals (CI) by asthma asthma is an important cause of occupational disability and status related economical costs (4.24. Those with intermittent mild disease are diluted in Asthma alone 1787 75 1. of events HR* HR  Outcome: all long-term work disability No asthma 62 755 (96. Claessen et al.82 (1. 2.4 times higher No asthma.71) comes (21).06) 1.50 (3. smoking. socioeconomic status.83 (4. Asthma. 1.78. sex.74 (1. 9.59.6 times.33) cases with psychological distress had 1. For example.06) tudes and beliefs about their illness may also impact out- No asthma.15) distress (24).68 (1. 2. psychosocial factors play a significant Disease status n events HR (95% CI)* role in the outcomes of patients with asthma. found strong associations between heavy bid conditions were obtained from national registers. smoking.24 (1.4) 127 2. Psychiatric dis- ease and psychosocial stress have been demonstrated to con- Outcome: all long-term work disability tribute to asthma morbidity and mortality. 20). all cases of asthma had to have ciated with increased risk of occupational disability among Allergy 66 (2011) 1598–1603 ª 2011 John Wiley & Sons A/S 1601 .00 (ref. 2. Asthma and long-term work disability Table 2 Long-term all-cause work disability (‡90 days) quantified by hazard ratios (HR) and 95% confidence intervals (CI) by asthma status Asthma n (%) No. Outcome: all long-term work disability Some limitations may be considered when interpreting the No asthma 62755 5098 1.32) the hazard ratios may have been lower. Table 3 Risk of long-term all-cause work disability quantified by asthma diagnosis confirmed both by the physician and by the hazard ratios (HR) and 95% confidence intervals (CI) by asthma SII.83) population sample. diabetes. we were able to take No. depression 2306 413 2. the fact that only definite asthma cases that have comorbidities special reimbursement for asthma medication and thus Outcome: disability pension chronic disease were included in the study strengthens the No asthma 62755 1812 1. Asthma + ‡2 chronic 62 23 4.63 (1. 1. rheumatic disease. 4. 2.Hakola et al. The observed prevalence of asthma in our study (3. 3. Smoking was asso- for special reimbursement. depression 2306 201 3.78) However. In addition. Table 4 Risk of long-term all-cause work disability quantified by In line with previous studies. depression and psychological Asthma and depression 154 37 3. and obesity. 8. no depression 60449 1611 1. These are in line with our results which showed that asthma alone increased the risk of long sickness absences *Adjusted for age. The use of reliable register information minimizes the status risks of measurement error and recall bias.88 (1. no depression 2042 102 1.6) 5098 1 (ref.74) incidence of long-term sickness absence than those without Asthma and depression 154 25 6. sex.6) 1812 1 (ref.91 (1.61. To be eligible because of mental and respiratory disease. such as socioeconomic status.33.5%) did not differ from other studies in Finland (3–11%) (17–19). have been linked to asthma (22–24).) ability.95) Outcome: disability pension No asthma 62 755 (96. We assume that if Asthma + 1 chronic 347 38 2. 6.53) employees with only self-reported asthma (including thus comorbidity intermittent mild asthma cases) were included in the analysis. and hypertension). important causes of sickness absence and work dis- Outcome: disability pension No asthma.24 (2.) 1 (ref.25) *Adjusted for age.79. and obesity. 9.8 times but together with depression by 3.57. 2.84 (1. smoking.3 to 1. 5. 2. and obesity. socioeconomic status. sex.45) 310 1. The study lacks information on asthma comorbidity symptoms and a detailed classification of asthma severity.49 (2. smoking. by 1.05 (1. Asthma + ‡2 chronic 62 14 5. malignancy. which smoking (‡20 cigarettes/day) and occupational disability in Finland are reliable and have high coverage. no depression 60449 4685 1.64. probably comorbidities those with mild or intermittent disease would be more likely *Adjusted for age.  Adjusted for (*) and presence of chronic comorbidities (depression.56.) Asthma 2196 (3. However.12) the large pool of healthy employees.) 1 (ref.) Asthma 2196 (3.00 (ref. often associated with self-reported measures. 3.) results.45 (2.60.42. of into account several potentially confounding factors in the Risk of work disability n events HR (95% CI)* analysis. and obesity. 10. In addition.) results of this study.58 (2.00 (ref. Patients’ coping No asthma. ischemic heart disease.96) distress. As in many other No of chronic conditions.00 (ref.22. socioeconomic status.

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