独立行政法人労働者健康安全機構 研究普及サイト

  • 文字サイズ小
  • 文字サイズ中
  • 文字サイズ大
リハビリテーション
ホーム » リハビリテーション »
DETERMINANTS OF EARLY RETURN TO WORK AFTER FIRST STROKE IN JAPAN

DETERMINANTS OF EARLY RETURN TO WORK AFTER FIRST STROKE IN JAPAN
―労災疾病等13分野研究・開発・普及事業における「職場復帰のためのリハビリテーション」より―」

Satoru Saeki, MD1 and Toshihiro Toyonaga, MD2

From the1 Department of Rehabilitation Medicine, University of Occupational and Environmental Health,School of Medicine, Kitakyushu and 2Kyushu Rosai Hospital Center for Preventive Medicine, Japan Labor Health Welfare Organization, Kitakyushu-city, Japan

Objective: To examine the time to return to work after first stroke and identify determinants of early return to work in Japan.
Design: A multicentre, prospective cohort study on the as sociation between characteristics at admission and early return to work after first stroke.Subjects: Among 464 patients after first stroke, 325 were registered in this study. All participants were younger than 65years and engaged in paid work at the time of the stroke.
Methods: Data collected prospectively for 18 months were analysed using the Kaplan-Meier method for time trends,and then a multiple logistic regression model for odds ratio of early to late return to work was conducted.
Results: Of the 325 registered patients (mean age 55.1, standard deviation (SD) 7.4 years), 253 (78%) were available for follow-up, and 138 (55%) returned to work. The curve of proportion of return to work was non-linear. Significant determinants of early return to work were gender, function of hemiplegic hand, and ability to perform activities of daily living independently.
Conclusion: The curve of time to return to work was influenced by the follow-up days. Patients after stroke who were male and/or had milder physical disabilities tended to return to work earlier.

Key words: stroke; vocational outcome; Japan.
J Rehabil Med 2010; 42: 254-258 Correspondence address: Satoru Saeki, Department of Rehabilitation Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka,Yahatanishi-ku, Kitakyushu 807―8555, Japan. E-mail: sae@med.uoeh-u.ac.jp Submitted June 3, 2009; accepted October 29, 2009

INTRODUCTION

Stroke is a source of major disability, particularly in older workers, and is associated with a substantial socioeconomic burden(1,2). The economic burden of stroke can be identified in terms of direct costs of providing medical care to patients and indirect costs associated with lost productivity (3). In 2004, the direct and indirect costs of stroke in the USA were estimated at $53.6billion, with a mean lifetime cost estimated at S140,048 per person (4). Indirect costs associated with lost productivity can be up to 58% of lifetime costs (3). Therefore, promoting early return to work (RTW) after stroke could help to reduce indirect costs associated with this disorder.
In addition to being an important outcome, RTW following stroke reflects a patient's social restoration. Vestling et al. (5) showed that having employment after a stroke promoted wellbeing and life satisfaction for patients. Although returning to work is a goal in post-stroke patients, the speed at which patients can return depends on their recovery (6). A rapid or early RTW indicates an early recovery and minimization of the significance of the stroke. Alaszewski et al. (6) defined rapid RTW after stroke as returning within 3 months from stroke onset. Similarly, another follow-up study in Japan (7) found 2 steep slopes in the RTW curve after stroke, and 2 groups of successful subjects who returned to work (early vs late RTW group). The early RTW group returned to work within 6 months post-stroke; in contrast, the late RTW group returned to work within 18 months post-stroke. Recently, in Japan, acute stroke therapy has been developed and a drastic change in the medical care system has taken place (8. 9). It is unknown, however, whether these changes influence time to RTW.
As reported in 24 studies, the proportion of subjects returning to work after stroke ranges from 11% to 85% (10). Although various studies have reported on RTW in diverse populations, these studies have different follow-up periods and use different definitions of stroke and successful work outcome (4), making comparisons between studies difficult. However, several predictors of RTW after stroke have been identified (3, 4, 10). Positive predictive factors include younger age, higher education level, and white-collar employment, whereas negative predictive factors include the severity of the stroke as determined by neurological parameters. Interestingly, the side of the brain damaged and the location of the stroke were not shown to be correlated with RTW (11, 12). Social and financial factors also significantly influenced RTW (7, 13).
Most previous studies have focused on whether the stroke patient could RTW, but there is a lack of data on early RTW after stroke. Early RTW after stroke is not only an important issue for individuals after stroke, but also an effective way to reduce associated indirect costs by reducing the number of lost work days. The purpose of the present study was to: (i) prospectively examine the current proportion and time trend of RTW post-stroke; and (ii) identify the determinants of earlier RTW in subjects who successfully RTW after stroke.

METHODS

Subjects
Subjects were recruited from 21 Rosai Hospitals throughout Japan. These hospitals were founded by JLHWO, one of the auxiliary organizations of the Ministry of Health, Labor and Welfare, to treat primarily ill and/or injured labourers. Each hospital follows the same medical protocols. Similar to other hospitals in Japan, these hospitals provide patients after stroke with standard therapy from the acute through the recovery stage, including medical rehabilitation.
Of the 464 patients after first stroke admitted to the hospitals between February 2006 and July 2007, an initial cohort (n = 325) was included in this study based on the following criteria: (i) first stroke; (ii) diagnosis of stroke (cerebral haemorrhage, cerebral infarction, or subarachnoid haemorrhage); (iii) age 15-64 years; and (iv) active employment status (full-time or part-time competitive employment, or self-employment) at stroke onset. We excluded patients whose occupation was classified as housewife or student.

Data collection
Sociodemographic, diagnostic, and functional data of subjects were prospectively assessed and collected in each hospital by hospital staff, including doctors, nurses, therapists, and medical social workers, using a unified data format entered on a secure website. The staff of each hospital registered the cases, input data in the required format, and transmitted data to the host computer at the head office of the project. The unified format consisted of 3 parts: (i) data at admission; (ii) data at discharge; and (iii) data at follow-up 18 months post-stroke.

Predictors
Potential predictors of early RTW were selected from the data gathered at admission based on a review of the literature (3, 4, 10) and included the following: age, gender, stroke subtype, occupation (white- or blue-collar), education level, marriage, previous alcohol consumption, hypertension, side and severity of hemiplegia, higher cortical dysfunctions (aphasia, agnosia, and apraxia), and ability to perform activities of daily living (ADL), as evaluated by Barthel Index (14).
Severity of hemiplegia was expressed as a function of the hemiplegic hand and leg based on the Brunnstrom stage (15), which is used widely in Japan: non-functional, stage 1-3; assistive, stage 4-5; and functional, stage 6. Higher cortical function was examined neurologically and any dysfunctions were distinguished. The Barthel Index assessed self-performance of ADL and categorized results as follows: 0-39, totally dependent; 40-79, partially dependent; or 80-100, independent.

Outcomess
The outcome was RTW after stroke, which was defined as active employment at the former or at a new occupation (full-time or part-time competitive employment, or self-employment). Data at follow-up 18 months after stroke onset included employment status, occupation, and the date of RTW after discharge. The follow-up period of 18 months was based on a previous study (7), which determined that the proportion of subjects returning to work after stroke reached a maximum level at 18 months and then plateaued, reflecting the time limit of patients' health benefits from the public fund source in Japan. Follow-up data were obtained using postal questionnaires at 18 months after stroke onset. When the questionnaire was incomplete, telephone interviews were conducted by medical social workers according to a common manual.
Of 325 registered stroke patients (mean and standard deviation (SD) age 55.1 years (SD 7.4), 253 (78%) answered the follow-up questionnaire. The mean age and the gender ratio of the 72 cases lost to follow-up were not significantly different from those of the 253 subjects included in the analysis.

Statistical analysis
The Kaplan-Meier method was used to calculate the proportion of subjects who experienced the event in question (RTW in this study) during the observation period. The length of observation was defined as follows. For censored cases of subjects who were followed up but did not return to work, the observation period was the interval between onset of stroke and the follow-up date of the response to the questionnaire; for non-censored cases (i.e. patients who returned to work successfully) the length of observation was the interval between the onset of stroke and the date of RTW. Because a previous study showed that the RTW curves, as assessed by the Kaplan-Meier method, were non-linear (7), we also performed logarithmic transformation of the observation period for the Kaplan-Meier curve.
We next examined the factors associated with early RTW in subjects who successfully returned to work. Because a previous study revealed that 50% of patients who successfully returned to work had returned to work within 100 days after stroke onset (7), we divided RTW cases into the early RTW group (< 100 days from stroke onset) and the late RTW group (>100 days from stroke onset). Univariate analysis was first performed to identify factors associated with early RTW using the X2 test. These factors were then incorporated as independent variables (the key variables), with early RTW as the dependent variable in the multiple stepwise logistic regression analysis. The logistic regression analysis computed odds ratios (ORs) to measure the association of each selected factor with early RTW, adjusting for other factors including the model.
We used JMP* (SAS Institute Inc., Cary, NC, USA) statistical software for statistical analyses.p<0.05 was considered significant.

RESULTS

A total of 138 patients (55%) reported successful RTW by 18 months after stroke onset (Table I). Plots of the cumulative proportion of subjects who successfully returned to work over time are shown in Fig. 1A. The curve is non-linear, with two steep curves, one during the first 400 days and the other during the next 100 days. This finding suggests that subjects who successfully returned to work included those in both the early and late RTW groups. Of the subjects who successfully returned to work, 50% returned to work within 100 days from onset. Fig. IB. shows plots of the cumulative proportion of subjects who successfully returned to work with the logarithmic transformation of the observation period. This graph is linear between 10 and 400 days follow-up, and also shows the cumulative 50% of cases who successfully returned to work at approximately 100 days.
 Univariate analysis showed the following factors were associated with early RTW: gender, function of the hand and leg with hemiplegia, and independence in performing ADL (TableI). Eleven cases with missing key variables were eliminated, leaving 127 patients as subjects for the multivariate analysis. Table Ⅱ shows the adjusted ORs of each predictor for early were 3 times more likely to return to work earlier than those who were totally dependent on others for ADLs.

Table I. Association betweenfactors at admission and early return to work after stroke among patients who successfully returned to work

1
2
Fig. 1. Proportion of subjects who successfully returned to work after first stroke by (A) Kaplan-Meier method, and (B) logarithmic transformation for follow-up days (n=253).

Table Ⅱ. Selectedfactors and adjusted odds ratios for early return to work after stroke among patients who successfully returned to work based on a stepwise logistic regression analysis (n = 127)]

Factor Odds ratio (95% CI)
Gender
1.00
Male 3.24*(1.11-10.96)
Function of the hand with hemiplegia
Assistive or non-functional 1.00
Functional 4.66*(1.40-19.53)
Function of the leg with hemiplegia
Assistive or non-functional 1.00
Functional 1.40(0.24-11.18)
ADL (Barthel Index)
Totally dependent (0-39) 1.00
Partially dependent (40-79) 2.35 (0.86-6.54)
Independent (80-100) 2.71*(I.08-7.03)

*p<0.05.
CI: confidence interval; ADL: activities of daily living.

DISCUSSION

This longitudinal study on RTW after first stroke among subjects younger than 65 years showed the current timeline for subjects to return to work after stroke as well as determinants of early RTW in Japan. Our study was a multicentre-based study, indicating that subjects were more representative of a general population than other hospital-based studies (10). Additionally, we used a prospective cohort design and a uniform follow-up time (18 months) for all subjects.
We found that 55% of the 253 first-stroke patients returned to work. Though caution is required when comparing the current RTW rate among countries due to the different backgrounds and methods, the rate of our subjects was higher than that in the UK (35%) (16) and similar to that in New Zealand (53%) (17). On the other hand, it is surprising that the rate of 55% was almost same as that in a previous study in Japan, performed 10 yeas ago, which reported a RTW rate of 58% (18), despite different medico-social backgrounds, subjects, and methods. The conditions for stroke rehabilitation in Japan have changed drastically over the past decade, including an increased incidence of ischaemic stroke (8), approval of intravenous recombinant tissue plasminogen activator (9). and hospital specialization influenced by the introduction of convalescent rehabilitation wards and public long-term care insurance. Regardless of those changes during the past decade in Japan, the steady rate of RTW may mean that the proportion of subjects who are able to return to work has reached its maximum. In this respect, not only the quantitative aspect of successful outcome in RTW, but also qualitative aspects, such as promoting early RTW, are important.
The curve of the cumulative proportion of subjects who successfully returned to work was non-linear, and had two steep slopes, one during the first 400 days and the other during the following 100 days. This finding is in agreement with the previous report that social factors, such as duration of sickness benefits, influenced RTW (7), and indicates that subjects who successfully returned to work included those in both the early and late RTW groups.
The graph of the logarithmic transformation of the observation period was linear between 10 and 400 days, and showed that the proportion of subjects who successfully returned to work between 20 and 40 days from stroke onset was the same as that between 200 and 400 days. The time-dependent curves of RTW may reflect the specificity of post-stroke disability beyond the change of medical and social conditions; however, the reconfirmed time-trend of RTW has been reported only in Japan. Further research is necessary to determine whether a similar time-trend may be seen in other countries where social and cultural backgrounds are different from Japan (10).
Though several studies have reported the predictors of overall successful RTW (3-7, 10-13, 18-22), to our knowledge, this is the first study to examine determinants of early RTW in post-stroke patients who successfully RTW in Japan.
Determinants of early RTW after stroke were different from those of overall successful RTW because the analyses included only subjects who returned to work. The multiple logistic regression model indicated that male gender, functional hand on hemiplegic side, and independence regarding ADL were positive predictors of early RTW among patients who successfully returned to work.
The association between gender and RTW varies in the literature (3, 10). Two early studies (11. 23) reported an association between the male gender and RTW. In contrast, several studies have found no association between gender and RTW (10, 18,20, 24). A recent study in the UK found that female gender was a negative predictor of RTW (16). Although it is unclear what caused these differences, we propose 2 possibilities: (i) female gender is generally associated with disadvantages in employment; and (ii) male patients may be forced to RTW earlier to support the household. Further studies are needed to identify the reasons for the differences between studies.
The function of the hand on the hemiplegic side and ADL measured by Barthel Index were positive predictors of early RTW. There was no correlation between these 2 factors, thus they should be considered separately. Many studies have found that the presence of greater severity of hemiplegia after stroke adversely affects RTW (3, 4, 7, 10, 18, 19). In particular, hand function of the hemiplegic side is an important factor in early RTW due to its direct influence on the ability to work.
Independence in performing ADL was most important for early discharge from the hospital, which precedes early RTW. Several studies have reported the association between independence in ADL and RTW after stroke (11, 16, 18, 20). Two studies showed that functional disability, as measured by the Barthel Index, is an important predictor of RTW (11, 16).
This study has several limitations. First, 22% of subjects were lost to follow-up. However, the characteristics of the cases lost to follow-up were not significantly different from those of subjects included in the analyses; therefore, the selection bias is likely to be small. Secondly, measurement or information bias may exist, especially from data obtained during the 18 months of follow-up using a postal questionnaire or telephone interview. However, the unified and common evaluation methods that were used in the 21 hospitals would minimize this bias. Thirdly, factors not included in our model may have increased the possibility of confounding. Finally, this study focused on the prognostic factors at initial evaluation on RTW, and changes or improvements in these factors during inpatient rehabilitation were not considered.
Despite these limitations, our study shows the time to RTW and the discriminants of early RTW after first stroke among Japanese patients. Future research on time to RTW in other countries focusing on the qualitative aspect of RTW is needed.
In conclusion, the results of this prospective study demonstrate that the curve of the cumulative proportion of subjects who successfully returned to work was non-linear and timedependent. In addition, male gender, functional hand on the hemiplegic side, and independently performing ADL were positive predictors of early RTW.

ACKNOWLEDGEMENTS

We thank Mikio Sumida, MD, Akihiro Tokuhiro, MD, Akihiro Toyota, MD, Hitoraka Tanaka, MD, and the staff of 21 Rosai Hospitals for data collection.

REFERENCES

  1. Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol 2009; 8: 345-354.
  2. Luengo-Fernandez R, Gray AM, Rothwell PM. Costs of stroke using patient-level data: a critical review of the literature. Stroke 2009;40:eI8-e23.
  3. Saeki S. Disability management after stroke: its medical aspects for workplace accommodation. Disabil Rehabil 2000; 22: 578-582.
  4. Tregrt I, Shames J, Giaquinto S, Ring H. Return to work in stroke patients. Disabil Rehabil 2007; 29: 1397-1403.
  5. Vestling M, Tufvesson B, Iwarsson S. Indicators for return to work after stroke and the importance of work for subjective well-being and life satisfaction. J Rehabil Med 2003; 35: 127-131.
  6. Alaszewski A, Alaszewski H, Potter J, Penhale B. Working after stroke: survivors' experiences and perceptions of barriers to and facilitators of the return to paid employment. Disabil Rehabil 2007;39:1858-1869.
  7. Saeki S, Ogata H, Okubo T, Takahashi K, Hoshuyama T. Return to work after stroke: a follow-up study. Stroke 1995; 26: 399-401.
  8. Shinohara Y. The changing face of the burden of stroke in Japan, lnt J Stroke 2007; 2: 133-135.
  9. Sato S, Uehara T, Toyoda K, Yasui N, Hata T, Ueda T, et al. Impact of the approval of intravenous recombinant tissue plasminogen activator therapy on the processes of acute stroke management in Japan: the stroke unit multicenter observational (SUMO) study. Stroke 2009; 40: 30-34.
  10. Wozniak MA, Kittner SJ. Return to work after ischemic stroke: a methodological review. Neuroepidemiology 2002; 21: 159―166.
  11. Wozniak MA, Kittner SJ, Price TR, Hebel JR, Sloan MA, Gardner JF. Stroke location is not associated with return to work after first ischemic stroke. Stroke 1999; 30: 2568-2573.
  12. Saeki S, Hachisuka K. The association between stroke location and return to work after first stroke. J Stroke Cerebrovasc Dis 2004; 13: 160-163.
  13. Heinemann AW, Roth EJ, Cichowski K, Betts MB. Multivariate analysis of improvement and outcome following stroke rehabilitation. Arch Neurol 1987; 44:1167-1172.
  14. MahoneyFI, BarthelDW. Functional evaluation; the Barthel Index. Maryland State Med Journal 1965; 14: 61-65.
  15. Brunnstrom S. Movement therapy in hemiplegia; a neurophysiological approach. New York: Harper & Row; 1970.
  16. Busch MA, Coshall C, Heuschmann PU, McKevitt C, Wolfe CDA. Sociodemographic differences in return to work after stroke: the South London Stroke Register (SLSR). J Neurol Neurosurg Psychiatry 2009; 80: 888-893.
  17. Glozier N, Hackett ML, Parag V, Anderson CS. The influence of psychiatric morbidity in return to paid work after stroke in younger adults. The Auckland Regional Community Stroke (ARCOS) Study, 2002 to 2003. Stroke 2008; 39: 1526-1532.
  18. Saeki S, Ogata H, Okubo T, Takahashi K, Hoshuyama T. Factors influencing return to work after stroke in Japan. Stroke 1993; 24: 1182-1185.
  19. Howard G, Till JS, Toole JF, Matthews C, Truscott BL. Factors influencing return to work following cerebral infarction. JAMA 1985; 253: 226-232.
  20. Black-Schaffer RM, Osberg JS. Return to work after stroke: development of a predictive model. Arch Phys Med Rehabil 1990; 71:285-290.
  21. Kotila M, Waltimo O, Niemi ML, Laaksonen R, Lempinen M. The profile of recovery from stroke and factors influencing outcome. Stroke 1984; 15: 1039-1044.
  22. Hinckley JJ. Vocational and social outcomes of adults with chronic aphasia. J Commun Disord 2002; 35: 543-560.
  23. Smolkin C, Cohen BS. Socioeconomic factors affecting the vocational success of stroke patients. Arch Phys Med Rehabil 1974; 55:269-271.
  24. Hsieh CL, Lee MH. Factors influencing vocational outcomes following stroke in Taiwan: a medical center-based study. Scand J Rehabil Medl997;29: 113-120.

方法

労災疾病13分野研究で収集されたデータを用い,身体機能・精神機能12項目、合併症5項目、社会的要因11項目、本人・家族の医師に関する3項目、復職の支援に関する8項目、全39項目について両群間で比較検討した。なお、全39項目について表1に示す。

表1 両群を比較した39項目

身体機能・精神機能 社会的要因
リハ開始時BI
退院時BT
退院時m-RS
上肢機能
下肢機能
歩行機能
退院時MMSE
失語
失行
失認
リハ開始までの日数
クリニカルパスの導入
年齢
性別
配偶者
勤続年数
通勤時間
経済的理由
会社からの復職に関する期待
役職
主な業種
退院時の雇用状況
就業形態
合併症能 復職の支援に関する項目
知能障害
注意障害
記低障害
易疲労性
肩関節亜脱臼
医療機関の復職に関する支援
職場の環境調整
職場の上司との連携
産業医との連携
職業リハ関係者との連携
入院中のMSWの関わり
入院中の職業リハ
医師から本人への働きかけ
本人・家族の意志に関する項目
退院時の家族の復職に対する意識
退院時の本人の復職希望
社会的無所属の不安

統計分析

両群の評価項目をt検定またはx2乗検定により比較した。なお、有意水準は5%未満とした。さらに、両群間の比較において有意差を認めた項目を独立変数、復職時期(早期・遅延)を従分析を実施した。

結果

1.両群の評価項目の比較
有意差を認めた項目は、1)リハ初回評価時BI、2)クリニカルパスの導入、3)易疲労性、4)社会的無所属の不安,5)医療機関の復職に関する支援の5項目であった.
1)リハ初回評価時BI
早期群の平均点は71.9±30.5点、遅延群の平均点は59.3±35.4点と、早期群ではリハ開始時BIの得点が高く、遅延群では得点が低い傾向にあった(p= 0.049).
2)クリニカルパスの導入
早期群ではクリニカルパスを導入した例が多く、遅延群では導入していない例が多かった(p= 0.035).また、クリニカルパス導入例は129例中33例(25.6%)と全体的に少なかった.
3)易疲労性
早期群では易疲労性ありが少なく、遅延群では易疲労性ありが多かった(p = 0.047).
4)社会的無所属の不安
早期群では不安ありが少なく、遅延群では不安ありが多かった(p=0.010).
5)医療機関の復職に関する支援
早期群では支援があったとした例が多く、遅延群では支援がなかったとした例が多かった(p=0.018). なお、豊永らの報告より脳血管障害者の退院時の復職可否に関連がみられた年齢、リハビリ開始までの日数,MMSE、業種、役職、患者や家族の復職の意志において、また発症1年半後の復職可否に関連がみられた年齢、退院時BI等の項目において復職時期との関連はみられなかった.

2.ロジステイック回帰分析
両群で有意差を認めたリハ初回評価時BI、クリニカルパスの導入、易疲労性、社会的無所属の不安、医療機関の復職に関する支援の5項目を独立変数、復職時期を従属変数としてロジステイック回帰分析を実施した。(表2)
復職時期には、リハ初回評価時BI(オッズ比:0.972).医療機関の復職支援(オッズ比:0.252)の2項目が影響しており、さらに医療機関の復職支援のオッズ比が高いことから、医療機関の復職支援の有無が復職支援に強く影響していることがわかった。

考察

今回の調査より、1)発症早期よりADL能力が高いこと、2)復職に適応する十分な体力があること、3)医療機関の復職に関する支援があることが早期復職可能要因であることかわかった。なおクリニカルパスの導入が有るほうが復職しやすいという結果が得られたが、データ収集時は脳血管障害に対するクリニカルパスの導入例が少なかったため復職時期の影響要因としては説得力に欠ける。しかし、脳血管障害の地域連携クリニカルパスが診療報酬で点数化された現在ではクリニカルパスの普及がいっそう進んでおり今後再度検討していく必要があると考える。また、社会的無所属の不安が有るほうが復職が遅延するという結果か得られたが、これは遅延群は早期群と比較して重症度が高く復職するためにより多くのプロセスを踏む必要があるためではないかと考える。
ロジステイック回帰分析の結果より、3)医療機関の復職に関する支援が復職時期に特に強い影響を与えていたことから、早い段階から医療機関が復職支援を実施していくことの重要性が再認識された。早期より機能評価に加え復職の評価を実施し、具体的な仕事内容を把握することで復職に必要な作業能力に対するアプローチを行うことが可能となるであろう。
また、豊永らの報告1)2)より、脳血管障害例が欲しかった復職支援として主に職業リハとの連携・産業医との連携が挙げられたが、実際に連携があったのはどちらも2割に満たないほど少なく(図2、図3)、復職支援が充実しているとは言えないのが現状である。医学的リハと職業リハとの連携は円滑とは言えない状況にあり、古澤らが述べるように適応となるものに対しても十分に受ける機会が与えられていない.さらに古潭らの調査によると、実際に職業リハの連携に対する援助をしたことがあるのは16%であるという現実がある。その理由としては、在院日数の短縮が進むことにより、「担当する期間か短い」、転院調整等日々の業務に追われており「業務に余裕がない」等が挙げられている11)。これは急性期病院のリハビリテーションスタッフに関しても同じことであり、限られた期間で行える業務には限界があり復職まで関われないことによって、復職支援に対する経験不足、理解不足が生じている。これらの対策として、MSWは「自分たちが窓口となる」,「職業リハに対する知識・向上を目指す」といった前向きな回答をしていることは明るい材料である。また、充実しているとは言えない中でも、13分野研究では職業リハや産業医、MSWと連携していたほうが復職しやすい2)という結果が得られており1)2)今後それらの充実が望まれる。
各施設の機能分化が進み、急性期、回復期、維持期というプロセスをたどっていく中で、転院や退院により環境が変わっても復職に関して一貫した支援を行える存在が必要とされ、それを担っていく復職コーディネーターの育成が急務である2)5)6)。今後、早期リハの実践と復職コーディネートをいかに適切に行っていくかが今後の労災病院群の課題であろう。

表3 復職時期を目的変数としたロジスティック回帰分析

因子 有意確率 オッズ比 オッズ比の95%信頼区間
下限 上限
リハ初回評価時のBI 0.000 0.972 0.958 0.987
医療機関の復職支援 0.031 0.252 0.072 0.882
優位性の無い変数 有意確率
易疲労性 0.808
クリニカルパスの導入 0.205

図1 復職率の経時的変化2)
復職率の経時的変化

図2 産業医との連携2)
産業医との連携

図3 職業リハとの連携2)
職業リハとの連携

表2 復職時期(早期群・遅延群での比較) pdf

文献

  1. 豊永敏宏:職場復帰のためのリハビリテーション―脳血管障害の退院時における職場復帰可否の要因―。日職災医学誌 56 : 135-145,2008.
  2. 豊永敏宏:脳血管障害者における復職復帰可否の要因―Phase3 (発症1年6ヵ月後)の結果から―。日職災医学誌 57 : 152―181,2009.
  3. 田中宏太佳、豊永敏宏:脳卒中患者の復職における産業医の役割―労災疾病等13分野医学研究・開発、普及事業における「職場復帰のためのリハビリテーション」分野の研究から―。日職災医学誌 57:29―38,2009.
  4. 独立行政法人労働者健康安全機構:「早期職場復帰を可能とする各種疾患に対するリハビリテーションのモデル医療の研究・開発、普及]研究報告書.2008.
  5. 豊田章宏:職場復帰のためのリハビリテーション―急性期医療の現場から―。日職災医学誌 57 : 227―232,2009.
  6. 深川明世:就労支援における作業療法の技術:障害特性を踏まえた就労計画の立て方:身体障害(脳血管障害)について.0Tジャーナル 43 : 771―775,2009.
  7. 佐伯 覚:脳卒中患者の職場復帰。日職災医学誌 51 :