146 Chapter 7 disease. Moreover, we found borderline significant associations (p<0.10) between inability to work fulltime and paid employment for working applicants with neoplasm and for non-working applicants diagnosed with a disease of the respiratory system. A possible explanation for the disease-specific findings is that diseases of the musculoskeletal system are mostly chronic conditions resulting in more physical (non-energetic) participation restrictions with a lower risk of being assessed with inability to work fulltime [2] while diseases resulting in energy deficits are known to be related with an inability to work fulltime [2]. As diseases of the musculoskeletal system usually have a stable prognosis regarding the limitations, and occupational physicians and employers are familiar with adjusting work to these limitations [17, 19-21] applicants who still (partly) work at the time of assessment will have a fair chance to remain in the adjusted work [22-24]. On the other hand, for cancer survivors it might be difficult to stay in paid employment due to the impact on energy levels and cognitive functioning [25-27]. This may explain the negative association which was found between inability to work fulltime and paid employment one year after the disability assessment. The findings for applicants not working at baseline with diseases of the respiratory system (e.g. pneumonia, emphysema, chronic obstructive pulmonary disease and pneumoconiosis), that inability to work fulltime lowers the chance of having paid work one year later, is in line with an international survey in 2011, showing that 40% of the working population had retired prematurely because of COPD [28]. Most of the diseases of the respiratory system are chronic with a negative effect on energy and endurance and with a higher risk [2] to be unable to work fulltime. The findings on multimorbidity may also be due to be more at risk for involuntary labour market exit in comparison to those workers without or with one a chronic health condition [29, 30]. Especially those applicants with multiple chronic diseases may not be able to work fulltime and will have more problems finding paid employment as they have more severe medical problems, resulting in more work limitations, than those diagnosed with one disease or those who are able to work fulltime. Strengths and limitations A strength of the study is the large sample size, including register data of a Dutch year cohort of applicants for work disability benefit, granted a partial disability benefit in 2016. Data included socio-demographics, all diagnoses, and monthly work status in 2016 and 2017. Furthermore, all assessments were carried out by skilled professionals, adhering to professional guidelines and assessment methods. Although the sample size of our study is large and the data are rich, possible confounders such as severity of diseases, symptoms of the diseases and the course of the disease after the assessment, and personal
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