Higher job exposures are associated with reduced return-to-work two years after rehabilitation in a nationwide cohort study based on German Pension Insurance data

Return-to-work (RTW) after medical rehabilitation is an important indicator of post-rehabilitation labour market participation, yet evidence on its association with occupation-based job exposure over longer follow-up periods remains limited. This nationwide retrospective cohort study examined the association between job exposure and RTW within 24 months post-rehabilitation using routine administrative data from the German Pension Insurance. The study included 621,695 individuals aged 18–63 years who completed medical rehabilitation between 2014 and 2019. Job exposure was assessed using the Overall Job Exposure Index, integrating physical and psychosocial exposures, and categorised into low, moderate, and high exposure. Initial RTW was defined as at least one month of employment, and stable RTW as at least four consecutive months within 24 months post-rehabilitation. Associations were analysed using Cox proportional hazards regression models with progressive adjustment for sociodemographic, work-related, and health-related factors. Within 24 months, 90.3% achieved initial RTW and 84.2% stable RTW. Higher job exposure was consistently associated with lower RTW rates. In fully adjusted models, moderate and high exposure were associated with a reduced likelihood of initial RTW (HR 0.903 [95% CI 0.897–0.909] and 0.872 [95% CI 0.866–0.878]) and stable RTW (HR 0.878 [95% CI 0.872–0.884] and 0.837 [95% CI 0.830–0.843]), compared with low exposure. These findings provide population-level evidence that occupation-based job exposure is associated with RTW after medical rehabilitation.