Background
Patients’ return to work is an important part of surgical counseling and quality of life.
Objective
This study aimed to evaluate the pattern of patients’ return to work and loss of productivity after pelvic reconstructive surgery.
Study Design
This was a secondary analysis of the randomized controlled trial Operations and Pelvic Muscle Training in the Management of Apical Support Loss. The primary outcome was return to work defined by the answer to “How many calendar weeks or workdays did you not go to work after the original prolapse surgery?” Furthermore, loss of productivity included hours and days per week worked and discontinuation of paid work because of urogynecologic conditions. Moreover, predictors affecting the timing of return to work and loss of productivity were assessed.
Results
Here, 180 patients (49%) were working before surgery. Of these patients, half returned to work 35 days after surgery, with 21 (13%) returning to work immediately after surgery and 43 (27%) returning to work within ≤2 weeks. The number of days missed did not differ between patients who underwent sacrospinous ligament fixation and those who underwent uterosacral ligament suspension ( P =.23). At 3 months, 15 patients (9%) who were working before surgery had stopped working, but those who continued to work had similar hours per week as before surgery (36±12 vs 35±13; P =.48). Of note, 17 patients (11%) reported being less productive, on average working at 60% effectiveness. Most patients (96%) reported not missing any hours of household chores by 3 months after surgery. Patients who returned to work within 6 weeks had a higher rate of retreatment with either pessary or surgery within 2 years (5 of 85 [6.8%] vs 0 of 76 [0%]; P =.03). Those who returned to work within 2 weeks worked fewer hours before surgery (30±15 vs 36±12; P =.013), were less likely to have private insurance (77% vs 91%; P =.03), and had a higher rate of retreatment (3 of 30 [13%] vs 2 of 131 [1.7%]; P =.007). There was no difference in bulge symptoms and anatomic failure based on return to work.
Conclusion
Most patients returned to work within 35 days after surgery. Working less than full time and not having private insurance were predictors of earlier return to work.
Why was this study conducted?
Timing for returning to work is an important part of surgical counseling and quality of life. We sought to evaluate the pattern of patients’ return to work and loss of productivity after prolapse surgery.
Key findings
Half of the patients who worked before pelvic reconstructive surgery missed <5 weeks of work after surgery. Working less than full time and not having private insurance were predictors of earlier return to work.
What does this add to what is known?
In general, after vaginal reconstructive surgery, women can consider returning to work at approximately 5 weeks. Women may be returning to work earlier because of other factors, such as financial constraints.
Introduction
One of the most important considerations for patients planning surgery is the time they will need to take off from work after the surgery. There is limited evidence regarding the timing of patients returning to work and loss of productivity after female pelvic reconstructive surgery. The Medical Disability Advisor, which is intended for employers to determine the duration of disability benefits, recommends 6 weeks for sedentary work and indefinite disability for physically demanding work after prolapse surgery. In general, these recommendations are based on surgical experience and traditional recommendations.
Understanding the trends in return to work and productivity loss can help patients and employers plan for recovery after surgery. Furthermore, evaluation of patient-reported actual timing of returning to work and loss of productivity after pelvic reconstructive surgery, rather than surgeon-recommended time off, will improve postoperative recommendations regarding recovery and function once a patient returns to work. The primary aim of this study was to evaluate the impact of vaginal reconstructive surgery on the time to return to work. The secondary aim of this study was to evaluate the percentage loss of productivity based on the question “During those days in the past month when you were not as productive at work, how would you rate your average level of effectiveness on a scale from 1 to 10 where 1 represents ‘not at all effective’ and 10 represents ‘fully effective’?”
Materials and Methods
This was a secondary, retrospective analysis of the randomized controlled trial (RCT) Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL). Data were obtained from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Data and Specimen Hub. This analysis was reviewed by the Hartford HealthCare Institutional Review Board and determined to be exempt.
The design and primary results of the OPTIMAL trial have been previously published. , The primary study design was a multicenter 2×2 randomized clinical trial: a surgical intervention (sacrospinous ligament fixation [SSLF] vs uterosacral ligament suspension [USLS]) and a perioperative behavioral intervention (behavioral and pelvic floor muscle training vs usual care). Both the control and experimental groups underwent vaginal prolapse repair with a tension-free vaginal tape (Ethicon Women’s Health and Urology, Somerville, NJ) for the treatment of stress urinary incontinence (SUI). This trial included 374 women undergoing surgery to treat both apical vaginal prolapse and SUI between 2008 and 2013.
The primary outcome of our secondary analysis was to explore the time to return to work after vaginal reconstructive surgery. Return to work was defined by the answer to “How many calendar weeks or workdays did you not go to work after the original prolapse surgery?” The secondary outcomes included loss of productivity, anatomic failure at 2 years, retreatment at 2 years, and bothersome vaginal bulge at 2 years. Furthermore, loss of productivity included answers to the following questions: “Are you doing any work for pay at present?”; “How many hours per week do you usually work?”; “How many days per week do you usually work?”; “You said that you are not currently working for pay. Is it because of any urologic or gynecologic condition, treatment of these conditions, or complications associated with these treatments?”; and “When did you stop working because of these reasons?” All OPTIMAL trial questions related to work and productivity are presented in the Supplemental Table . Anatomic failure was defined as descent beyond the hymen. Retreatment was defined as retreatment for prolapse or urinary incontinence.
Patient characteristics, including demographic, clinical, and surgical variables, were evaluated using univariate analysis. Continuous, normally distributed data were compared using the 2-sample t test between patients who returned to work before and after 2 weeks and patients who returned to work before and after 6 weeks. Categorical variables were compared using a chi-squared or the Fisher exact test as appropriate. Nonparametric data were compared using the Wilcoxon rank-sum test. Univariate analyses were used to evaluate potential predictors affecting the timing of return to work and loss of productivity. Multivariate regression analysis was performed to assess potential independent predictors of the timing of returning to work. Significant predictor variables from the univariate analyses and clinically relevant potential confounders were included in the analysis. A similar multivariate regression analysis was performed to assess return to work as a potential independent predictor of treatment outcome. Data were analyzed using Stata software (StataCorp. 2019. Stata Statistical Software: Release 16. StataCorp LLC, College Station, TX).
Results
In the OPTIMAL trial, 180 patients (49%) were working before surgery. These patients worked an average of 35±13 hours per week. Of patients who worked before surgery, the median number of workdays missed immediately after surgery was 35 days (range, 0–210 days). Among these patients, 21 (13%) did not miss any work after their hospital stay for surgery, 27 (17%) missed a week or less, 43 (27%) missed ≤2 weeks, 68 (42%) missed ≤4 weeks, and 130 (81%) missed ≤6 weeks. At 3 months, 15 patients (9%) who were working before surgery had stopped working, but those who continued to work had similar hours per week as before surgery (36±12 vs 35±13; P =.48). The length of hospital stay ranged from 1 to 5 days, with most patients (87%) staying for 2 to 3 days.
The Figure shows the distribution of time to return to work for patients in the USLS arm and the SSLF arm. The number of days missed did not differ between patients who underwent SSLF and those who underwent USLS ( P =.23).
In terms of loss of productivity at 3 months, 17 patients (11%) who were working reported being less productive at work. Half of these patients reported being less productive for 4 days per month, and 25% of patients reported being less productive for >6 days per month. On average, patients being less productive at work reported working at approximately 60% effectiveness. Most patients (96%) reported not missing any hours of household chores by 3 months after surgery.
Patients who missed <6 weeks of work had fewer days per month where they were less productive at work at baseline before surgery than patients who missed ≥6 weeks of work after surgery (6.5±7.1 vs 11.0±8.3; P =.03). After surgery, patients who returned to work in <6 weeks had a higher rate of retreatment with either pessary or surgery within 2 years (5 of 85 [6.8%] vs 0 of 76 [0%]; P =.03) ( Table 1 ). There were no other differences in patient characteristics, perioperative factors, and outcomes between the 2 groups.
| Characteristic | Returned to work within 2 wk (n=30) | Returned to work after 2 wk (n=131) | P value | Returned to work within 6 wk (n=85) | Returned to work after 6 wk (n=76) | P value |
|---|---|---|---|---|---|---|
| Age (y) | 55.0±12.0 | 54.0±8.2 | .366 | 54.0±9.8 | 54.0±7.8 | .836 |
| Body mass index (kg/m 2 ) | 29.0±6.2 | 29.0±5.4 | .973 | 28.0±5.2 | 29.0±5.8 | .138 |
| Race | .683 | .071 | ||||
| White | 26 (87.0) | 110 (84.0) | 77 (91.0) | 59 (78.0) | ||
| Black or African American | 2 (6.7) | 6 (4.6) | 3 (3.5) | 5 (6.6) | ||
| Other | 2 (6.7) | 15 (11.0) | 5 (5.9) | 12 (16.0) | ||
| Hispanic | 6 (20.0) | 19 (14.0) | .453 | 12 (14.0) | 13 (17.0) | .601 |
| POP-Q stage | .799 | .530 | ||||
| I | 0 (0) | 0 (0) | 0 (0) | 0 (0) | ||
| II | 13 (43.0) | 65 (50.0) | 38 (45.0) | 40 (53.0) | ||
| III | 16 (53.0) | 61 (46.0) | 43 (50.0) | 34 (45.0) | ||
| IV | 1 (3.3) | 5 (3.8) | 4 (4.7) | 2 (2.6) | ||
| Diabetes mellitus | 4 (13.0) | 11 (8.6) | .425 | 5 (6.0) | 10 (13.0) | .118 |
| Private insurance | 23 (77.0) | 119 (91.0) | .030 | 75 (88.0) | 67 (88.0) | .998 |
| Operative time (min) | 157±49 | 159±45 | .790 | 161±45 | 156±45 | .519 |
| Estimated blood loss (mL) | 232±147 | 213±140 | .526 | 224±139 | 209±143 | .532 |
| Length of hospital stay (d) | 2.4±0.9 | 2.3±0.6 | .418 | 2.2±0.7 | 2.3±0.7 | .238 |
| Surgical treatment | .910 | .392 | ||||
| Sacrospinous ligament fixation | 15 (50.0) | 67 (51.0) | 46 (54.0) | 36 (47.0) | ||
| Uterosacral ligament suspension | 15 (50.0) | 64 (49.0) | 39 (46.0) | 40 (53.0) | ||
| Pelvic muscle training | 16 (53.0) | 61 (46.0) | .503 | 39 (46.0) | 38 (50.0) | .602 |
| Work missed after surgery (d) | 0 (0.0–2.0) | 42 (28.0–42.0) | <.001 | 14 (1.4–28.0) | 42 (42.0–56.0) | <.001 |
| Before surgery | ||||||
| Hours worked per week | 30±15 | 36±12 | .013 | 34±14 | 37±11 | .205 |
| Days per month less productive | 10.0±9.9 | 8.5±7.8 | .544 | 6.5±7.1 | 11.0±8.3 | .033 |
| Level of productivity a | 5.1±1.6 | 6.3±1.9 | .097 | 6.1±1.9 | 6.2±1.9 | .761 |
| Hours per week missed housework | 0.6±1.6 | 0.7±1.6 | .725 | 0.7±1.6 | 0.7±1.6 | .847 |
| 3 mo after surgery | ||||||
| Hours worked per week | 28±15 | 36±12 | .009 | 34±15 | 36±11 | .375 |
| Days per month less productive | — | 5.7±3.9 | — | 6.0±3.9 | 5.5±4.1 | .816 |
| Level of productivity a | — | 6.4±1.6 | — | 6.2±2.1 | 6.5±1.3 | .699 |
| Hours per week missed housework | 0 | 0.1±0.6 | .363 | 0.06±0.40 | 0.1±0.7 | .535 |
| 24 mo after surgery | ||||||
| Hours worked per week | 31±11 | 38±13 | .035 | 36±13 | 39±12 | .158 |
| Days per month less productive | — | 9.4±7.3 | — | 12.0±12.0 | 8.0±5.3 | .671 |
| Level of productivity a | — | 7.6±1.8 | — | 6.5±2.1 | 8.3±1.5 | .334 |
| Hours per week missed housework | 0 | 0.008±0.090 | .659 | 0 | 0.02±0.12 | .291 |
| Anatomic failure at 24 mo b | 5 (22.0) | 22 (19.0) | .759 | 15 (21.0) | 12 (18.0) | .663 |
| Retreatment at 24 mo c | 3 (13.0) | 2 (1.7) | .007 | 5 (6.8) | 0 (0) | .032 |
| Any bothersome bulge at 24 mo d | 6 (27.0) | 20 (18.0) | .317 | 16 (23.0) | 10 (16.0) | .353 |
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