Association Between Newly Diagnosed Atrial Fibrillation and Work Disability (from a Nationwide Danish Cohort Study)

It is previously shown that cardiovascular conditions have a negative effect on the ability to work. However, it is unknown if incident atrial fibrillation (AF) influences the ability to work. We examined the association between AF and the risk of work disability and the influence of socioeconomic factors. All Danish residents with a hospital diagnosis of AF and aged ≥30 and ≤63 years in the period January 1, 2000, to September 31, 2014, were included and matched 1:10 with an AF-free gender and age-matched random person from the general population. Permanent social security benefit was used as a marker of work disability. Risk difference (RD) and 95% confidence interval (95% CI) of work disability were calculated over 15 months. The analyses were furthermore stratified in low, medium, and high levels of socioeconomic factors. In total, 28,059 patients with AF and 312,667 matched reference persons were included. The risk of receiving permanent social security benefits within 15 months was 4.5% (4.3% to 4.8%) for the AF cohort and 1.3% (95% CI 1.3% to 1.4%) for the matched reference cohort. Adjusted RD (95% CI) was 2.3% (2.0% to 2.5%). Stratified on income, RDs were higher in low-income groups (adjusted RD 3.7% [95% CI 3.1% to 4.3%]) versus high-income groups (RD 1.3% [1.0% to 1.5%]). In conclusion, the risk of work disability within 15 months after incident AF was more than 3 times as high in patients with AF compared with the general population, especially when comparing individuals in lower socioeconomic strata. It is previously shown that cardiovascular conditions have a negative effect on the ability to work. However, it is unknown if incident atrial fibrillation (AF) influences the ability to work. We examined the association between AF and the risk of work disability and the influence of socioeconomic factors. All Danish residents with a hospital diagnosis of AF and aged ≥30 and ≤63 years in the period January 1, 2000, to September 31, 2014, were included and matched 1:10 with an AF-free gender and age-matched random person from the general population. Permanent social security benefit was used as a marker of work disability. Risk difference (RD) and 95% confidence interval (95% CI) of work disability were calculated over 15 months. The analyses were furthermore stratified in low, medium, and high levels of socioeconomic factors. In total, 28,059 patients with AF and 312,667 matched reference persons were included. The risk of receiving permanent social security benefits within 15 months was 4.5% (4.3% to 4.8%) for the AF cohort and 1.3% (95% CI 1.3% to 1.4%) for the matched reference cohort. Adjusted RD (95% CI) was 2.3% (2.0% to 2.5%). Stratified on income, RDs were higher in low-income groups (adjusted RD 3.7% [95% CI 3.1% to 4.3%]) versus high-income groups (RD 1.3% [1.0% to 1.5%]). In conclusion, the risk of work disability within 15 months after incident AF was more than 3 times as high in patients with AF compared with the general population, especially when comparing individuals in lower socioeconomic strata. Atrial fibrillation (AF) was for many years considered a trivial condition, but it is now recognized as a contributor to mortality and morbidity1Lip GY Kakar P Watson T. Atrial fibrillation–the growing epidemic.Heart. 2007; 93: 542-543Google Scholar such as heart failure (HF) and stroke.2Zoni-Berisso M Lercari F Carazza T Domenicucci S. Epidemiology of atrial fibrillation: European perspective.Clin Epidemiol. 2014; 6: 213-220Google Scholar Nevertheless, although the fatal consequences of AF are being increasingly recognized, the social consequences after AF are less examined. It is previously shown that cardiovascular conditions such as congenital heart disease,3Nyboe C Fonager K Larsen ML Andreasen JJ Lundbye-Christensen S Hjortdal V. Effect of atrial septal defect in Adults on Work Participation (from a Nation Wide Register-Based Follow-Up Study Regarding Work Participation and Use of Permanent Social Security Benefits).Am J Cardiol. 2019; 124: 1775-1779Google Scholar myocardial infarction,4Smedegaard L Numé AK Charlot M Kragholm K Gislason G Hansen PR Return to work and risk of subsequent detachment from employment after myocardial infarction: insights from Danish nationwide registries.J Am Heart Assoc. 2017; 6e006486Google Scholar HF,5Rørth R Wong C Kragholm K Fosbøl EL Mogensen UM Lamberts M Petrie MC Jhund PS Gerds TA Torp-Pedersen C Gislason GH McMurray JJ Køber L Kristensen SL. Return to the workforce after first hospitalization for heart failure: a Danish nationwide cohort study.Circulation. 2016; 134: 999-1009Google Scholar or cardiac arrest6Kragholm K Wissenberg M Mortensen RN Fonager K Jensen SE Rajan S Lippert FK Christensen EF Hansen PA Lang-Jensen T Hendriksen OM Kober L Gislason G Torp-Pedersen C Rasmussen BS. Return to work in out-of-hospital cardiac arrest survivors: a nationwide register-based follow-up study.Circulation. 2015; 131: 1682-1690Google Scholar have a negative effect on the ability to work. Some of the mentioned studies4Smedegaard L Numé AK Charlot M Kragholm K Gislason G Hansen PR Return to work and risk of subsequent detachment from employment after myocardial infarction: insights from Danish nationwide registries.J Am Heart Assoc. 2017; 6e006486Google Scholar, 5Rørth R Wong C Kragholm K Fosbøl EL Mogensen UM Lamberts M Petrie MC Jhund PS Gerds TA Torp-Pedersen C Gislason GH McMurray JJ Køber L Kristensen SL. Return to the workforce after first hospitalization for heart failure: a Danish nationwide cohort study.Circulation. 2016; 134: 999-1009Google Scholar, 6Kragholm K Wissenberg M Mortensen RN Fonager K Jensen SE Rajan S Lippert FK Christensen EF Hansen PA Lang-Jensen T Hendriksen OM Kober L Gislason G Torp-Pedersen C Rasmussen BS. Return to work in out-of-hospital cardiac arrest survivors: a nationwide register-based follow-up study.Circulation. 2015; 131: 1682-1690Google Scholar also reported that high levels of socioeconomic factors (SEFs) were associated with a higher likelihood of returning to work after incident myocardial infarction, HF, or cardiac arrest, respectively. To our knowledge, no study has examined the association between AF and the risk of permanent work disability and the influence of SEFs. The study aimed to examine the association between incident AF and the risk of work disability and if SEFs have an influence. The study was designed as a register-based cohort study using individual-level data from nationwide Danish registers accessed at Statistics Denmark.7Thygesen LC Daasnes C Thaulow I Brønnum-Hansen H. Introduction to Danish (nationwide) registers on health and social issues: structure, access, legislation, and archiving.Scand J Public Health. 2011; 39: 12-16Google Scholar The Danish National Patient Registry has information about diagnoses and procedures where diagnoses are coded according to the International Classification of Diseases (ICD), version 8 before 1994 and ICD-10 afterwards.8Lynge E Sandegaard JL Rebolj M. The Danish National patient register.Scand J Public Health. 2011; 39: 30-33Google Scholar,9Schmidt M Schmidt SA Sandegaard JL Ehrenstein V Pedersen L Sørensen HT. The Danish National patient registry: a review of content, data quality, and research potential.Clin Epidemiol. 2015; 7: 449-490Google Scholar The Danish National Prescription Registry keeps information on dispensed prescriptions from Danish pharmacies since the year 1994. Prescriptions are coded using the Anatomical Therapeutic Chemical system.10Kildemoes HW Sørensen HT Hallas J. The Danish National Prescription Registry.Scand J Public Health. 2011; 39: 38-41Google Scholar Income register and educational registers are also available through Statistics Denmark.11Baadsgaard M Quitzau J. Danish registers on personal income and transfer payments.Scand J Public Health. 2011; 39: 103-105Google Scholar,12Jensen VM Rasmussen AW. Danish education registers.Scand J Public Health. 2011; 39: 91-94Google Scholar The Danish Civil Registration system keeps information such as vital status, gender, and place of residence on all residents living in Denmark.13Pedersen CB. The Danish civil registration system.Scand J Public Health. 2011; 39: 22-25Google Scholar Information about social security benefits transfer was obtained from the DREAM database which keeps the information about public transfer payments for Danish citizens each week.14Hjollund NH Larsen FB Andersen JH. Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a population-based survey.Scand J Public Health. 2007; 35: 497-502Google Scholar All persons living in Denmark have a personal identification number that can be used to link data across registers at an individual level.7Thygesen LC Daasnes C Thaulow I Brønnum-Hansen H. Introduction to Danish (nationwide) registers on health and social issues: structure, access, legislation, and archiving.Scand J Public Health. 2011; 39: 12-16Google Scholar,13Pedersen CB. The Danish civil registration system.Scand J Public Health. 2011; 39: 22-25Google Scholar We included all patients ≥30 and ≤63 years old with incident AF and/or atrial flutter (ICD-10 Code I48) and followed them from January 1, 2000 to December 31, 2015. To have a complete follow-up on all patients, inclusion ended September 30, 2014. The combined diagnosis of AF and atrial flutter had a high validity (positive predictive value 92.6%).15Rix TA Riahi S Overvad K Lundbye-Christensen S Schmidt EB Joensen AM. Validity of the diagnoses atrial fibrillation and atrial flutter in a Danish patient registry.Scand Cardiovasc J. 2012; 46: 149-153Google Scholar Information about symptoms was not available in the registers. To obtain a reference cohort from the general population, patients with AF were matched on gender and date of birth in ratio 1:10 with random unexposed (at the date of matching) persons from the general population using the Danish Civil Registration System. The date of discharge for incident AF was used as the date of matching (index date).3Nyboe C Fonager K Larsen ML Andreasen JJ Lundbye-Christensen S Hjortdal V. Effect of atrial septal defect in Adults on Work Participation (from a Nation Wide Register-Based Follow-Up Study Regarding Work Participation and Use of Permanent Social Security Benefits).Am J Cardiol. 2019; 124: 1775-1779Google Scholar We excluded patients who received permanent social security benefits defined as disability pension, flexi-job (can be awarded if the ability to work of a person is permanently and significantly reduced), or early retirement in the 4 weeks before incident AF.3Nyboe C Fonager K Larsen ML Andreasen JJ Lundbye-Christensen S Hjortdal V. Effect of atrial septal defect in Adults on Work Participation (from a Nation Wide Register-Based Follow-Up Study Regarding Work Participation and Use of Permanent Social Security Benefits).Am J Cardiol. 2019; 124: 1775-1779Google Scholar,14Hjollund NH Larsen FB Andersen JH. Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a population-based survey.Scand J Public Health. 2007; 35: 497-502Google Scholar Additionally, we excluded patients with missing data on SEFs. Permanent social security benefits, including disability pension and flexi-job (a job created for persons with limited and permanently reduced work capacity),3Nyboe C Fonager K Larsen ML Andreasen JJ Lundbye-Christensen S Hjortdal V. Effect of atrial septal defect in Adults on Work Participation (from a Nation Wide Register-Based Follow-Up Study Regarding Work Participation and Use of Permanent Social Security Benefits).Am J Cardiol. 2019; 124: 1775-1779Google Scholar was used as a marker of work disability. The time to being on permanent social security benefits was in this study defined as the first date of the first 4 weeks receiving transfer payments for disability pension, flexi-job, or unemployment benefit concerning flexi-job3Nyboe C Fonager K Larsen ML Andreasen JJ Lundbye-Christensen S Hjortdal V. Effect of atrial septal defect in Adults on Work Participation (from a Nation Wide Register-Based Follow-Up Study Regarding Work Participation and Use of Permanent Social Security Benefits).Am J Cardiol. 2019; 124: 1775-1779Google Scholar,14Hjollund NH Larsen FB Andersen JH. Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a population-based survey.Scand J Public Health. 2007; 35: 497-502Google Scholar within 15 months. In addition to permanent social security benefits, we used the work participation score (WPS) as an outcome measure for job retention. WPS was calculated in a 3-month period starting 12 months after incident AF. We chose 1 year after incident AF as we wanted to look at the working ability after the acute phase, and not in relation to AF hospitalization. Work status was defined as WPS from 0% to 100% where the number of weeks being self-supported (defined as no public transfer payment, State Education Fund Grant, maternity leave or leave-of-absence scheme6Kragholm K Wissenberg M Mortensen RN Fonager K Jensen SE Rajan S Lippert FK Christensen EF Hansen PA Lang-Jensen T Hendriksen OM Kober L Gislason G Torp-Pedersen C Rasmussen BS. Return to work in out-of-hospital cardiac arrest survivors: a nationwide register-based follow-up study.Circulation. 2015; 131: 1682-1690Google Scholar,14Hjollund NH Larsen FB Andersen JH. Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a population-based survey.Scand J Public Health. 2007; 35: 497-502Google Scholar) were placed in the numerator and the number of weeks receiving social security benefits and the number of weeks being self-supported in the denominator (13 weeks in total).16Biering K Hjøllund NH Lund T. Methods in measuring return to work: a comparison of measures of return to work following treatment of coronary heart disease.J Occup Rehabil. 2013; 23: 400-405Google Scholar In this analysis we only included in the study population being at the of 15 months and not receiving permanent social security benefits the and status were defined as previously Joensen Fonager K Lundbye-Christensen S Larsen ML Riahi S. in in patients with atrial fibrillation with high risk of a register-based Scholar In income was defined as the income and Joensen Fonager K Lundbye-Christensen S Larsen ML Riahi S. in in patients with atrial fibrillation with high risk of a register-based Scholar Education was 3 lower or education or less if date of birth was and degree or less if date of birth was and high degree and more if date of birth was and degree if date of birth was Joensen Fonager K Lundbye-Christensen S Larsen ML Riahi S. in in patients with atrial fibrillation with high risk of a register-based Scholar status was living or living with Joensen Fonager K Lundbye-Christensen S Larsen ML Riahi S. in in patients with atrial fibrillation with high risk of a register-based Scholar residence was as previously Joensen Fonager K Lundbye-Christensen S Larsen ML Riahi S. in in patients with atrial fibrillation with high risk of a register-based Joensen Lundbye-Christensen S Fonager K S Larsen ML M Riahi S and risk of atrial fibrillation: a nationwide Danish cohort Health. Scholar 4 of and of and The Danish on December Scholar The as were HF, heart and The Therapeutic used in this study are in were for patients with AF and matched individuals with and for the and and for the and WPS were calculated in a 3-month period 1 year before incident AF to months to to obtain an of work disability in AF cohort and matched reference we status in the period to 3 years after the date social security or The patients were according to first The mortality included after other as in with M L Christensen and of in patients with atrial fibrillation: a Danish nationwide cohort Scholar in a of 15 we calculated risk of receiving permanent social security benefits in 15 months not be to be permanent social security benefits be However, if we than 15 other with time be more of receiving permanent social security we chose 15 months to risk and risk difference (RD) of receiving permanent social security benefits it is to be to AF and it also be for patients to be permanent social security The RDs were calculated using a R Scholar with an link and to for a that was not pension, and early retirement were considered as We for and the were before data we for in gender, income, status, and we for in heart and be a or in the between AF and permanent social security we a 3 and for and which are all risk factors for permanent work disability. are also consequences of only associated with the risk of AF through risk factors. We considered as the of for of the of all were stratified on SEFs. We used the to for effect for SEFs. we also the risk of permanent work disability stratified on groups to to and to In a of the population, and to work 15 months after the we calculated the WPS over a 3-month period starting 12 months after the who received permanent social security benefits, pension, or early pension within 15 months of the were not included in this We used to the difference in WPS between the matched reference cohort versus the AF cohort. To the of WPS and we used with to we stratified the analysis on income, and we for gender, and WPS the and cohort were after individuals and on SEFs. We used version for value was considered In total, patients with AF and AF-free matched individuals aged ≥30 to ≤63 years old were included in the period January 1, 2000 to September 31, 2014. patients with missing on SEFs and permanent social security benefits or early 28,059 patients with AF and 312,667 matched individuals were included in the study population. patients with AF and individuals in the matched reference cohort were used to WPS in the are in In the matched reference were in the AF cohort were was and years for the matched reference cohort and the AF respectively. income were defined on the income of the of the general population before and are not as in this study population. All were more in the AF cohort than in the matched reference especially cardiovascular with AF received more permanent social security benefits and had higher mortality than the matched reference cohort the and the matched reference cohort and the AF cohort received the of early retirement and pension of the study if is difference in of the in the between AF cohort and matched reference cohort. in the period to months to heart failure years years old and 1 heart or if is difference in of the in the between AF cohort and matched reference in the period to months to heart failure years years old and 1 in a for patients with AF and matched reference cohort years after date social security or according to first The mortality included mortality after other The 15 months. The matched reference cohort was matched on and the risk of receiving permanent social security benefits was 4.5% (95% CI to 4.8%) in the AF it was 1.3% (95% CI 1.3% to 1.4%) in the matched reference cohort. for the RDs were the on income, and status, RDs for the AF cohort were in the with income, and living and in groups with high high income, and not living The risk of permanent work disability was in all the to to and to the association was in the cohort difference of permanent social security benefit for patients with AF versus matched individuals stratified on groups of socioeconomic for AF for reference and 95% CI and 95% CI and 95% CI to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to to gender, income, education and 1 and HF, and and and atrial CI confidence coronary heart RD risk if effect income and status was in a gender, income, education and 1 and HF, and and and AF atrial CI confidence coronary heart RD risk if effect income and status was individuals and to work 15 months after the AF cohort had a lower WPS than the matched reference WPS for the matched reference cohort was it was for the AF cohort and RD for the patients with AF was (95% CI to The with income and status as for permanent work disability was for WPS and for the matched reference cohort and the AF cohort are in for effect for SEFs that effect was for income and for status and participation score (WPS) difference for patients with AF the stratified on groups of socioeconomic WPS for AF WPS for reference to to to to to to to to to to to to to to to to to to atrial CI confidence WPS work participation for WPS and if effect income and status was in a AF atrial CI confidence WPS work participation for WPS and if effect income and status was were individuals with AF aged between ≥30 and ≤63 years old had a higher risk of permanent work disability than the matched reference patients with AF and a of the workforce 15 months after incident AF had a lower WPS than the matched reference was effect the difference in permanent social security benefits and WPS was in including persons with lower lower income and living the risk and difference were in including persons with higher higher income and not living have shown an association between detachment from employment for myocardial L Numé AK Charlot M Kragholm K Gislason G Hansen PR Return to work and risk of subsequent detachment from employment after myocardial infarction: insights from Danish nationwide registries.J Am Heart Assoc. 2017; 6e006486Google Scholar and R Wong C Kragholm K Fosbøl EL Mogensen UM Lamberts M Petrie MC Jhund PS Gerds TA Torp-Pedersen C Gislason GH McMurray JJ Køber L Kristensen SL. Return to the workforce after first hospitalization for heart failure: a Danish nationwide cohort study.Circulation. 2016; 134: 999-1009Google Scholar a study that AF and other heart a to the workforce of in the working population and of and from SA JL The of atrial fibrillation and other cardiac in an associated and Occup Scholar we to an association between AF and permanent work disability. this It is that work disability was consequences of AF such as especially if were permanent social security benefit within only 15 months. if a person was of an that the ability to work be and the person of permanent social security benefit within 15 months. treatment such as for to patients with AF and with a high risk of have shown that this is especially in patients with socioeconomic Joensen Fonager K Lundbye-Christensen S Larsen ML Riahi S. in in patients with atrial fibrillation with high risk of a register-based Scholar In other work disability in patients with AF be through the consequences of AF such as and it also the difference was in lower socioeconomic consequences of AF an in the between AF and work a study reported that 1 of 3 patients with AF had of and G GY and of in patients with atrial 2007; Scholar and are of the of disability pension and in for 2015. on December Scholar AF to symptoms of and/or which work and work look more the of in patients with AF with work and work public health for and treatment to the for AF In the this the and health to AF. We also that the risk of work disability in the AF cohort versus matched reference cohort was more in individuals with lower lower income, and living than in with higher higher income, and not living that SEFs an in lower ability to work for patients with AF. Some be of the of this no can be is an unknown factors and factors which we we have information on patients with or at the patients with are general from we not have the in 1 that of the matched reference cohort and patients with AF had is The for it have to many patients after a diagnosis of AF and were we not have information on factors to work and such as of job L Numé AK Charlot M Kragholm K Gislason G Hansen PR Return to work and risk of subsequent detachment from employment after myocardial infarction: insights from Danish nationwide registries.J Am Heart Assoc. 2017; 6e006486Google Scholar we have information on the of received permanent social security we not if it was were or although Denmark is a with social to all factors with income and WPS for the AF cohort and the matched reference cohort not the WPS in an population with AF or the general population we excluded all persons who in the period or received permanent social be with Some be in is in the using nationwide registers we were to obtain a population of patients with AF. Danish nationwide registers are of high with complete M Schmidt SA Sandegaard JL Ehrenstein V Pedersen L Sørensen HT. The Danish National patient registry: a review of content, data quality, and research potential.Clin Epidemiol. 2015; 7: 449-490Google Scholar using nationwide the risk of and was in all citizens have the to be to social security benefits if are not of a job of or receiving a permanent social security benefit be to be a marker of work disability. In conclusion, incident AF is associated with a higher risk of work disability. patients with AF and working 1 year after the incident AF had lower work participation than the general population. the of patients with AF be to patients with AF in the for cardiovascular risk patient and of The have no of to to data is only to who are for the according to Danish data from this be The for with data and for the general of this with data with this can be in the at