The prevalence and incidence of DP among patients with a first coronary revascularisation seemed to be higher than among those in the general population, indicated by the national DP statistics. The prevalence and incidence of DP was high in Sweden during the years studied of this thesis. Further, the interventions (CABG and PCI) have been improved over the past decades (14). Therefore, to get a picture of the DP situation among patients with a coronary revascularisation of today, it would be fruitful to also study DP in present time.
More than half of the patients had been on DP for at least 4 and up to 35 years before the intervention. Although the indication for the intervention was CVD; more were on DP due to musculoskeletal DP diagnoses, in general as well as in most of the studied subgroups. This implies that many had been outside the labour market for many years before the intervention.
Maybe musculoskeletal disorders, that were so severe that they lead to DP, could be
associated with the CVD in itself. Another possibility is that being on DP in itself is either a risk factor or a risk indicator for CVD. This indicates that the patients’ medical history, beyond CVD, is of importance for those undergoing coronary revascularisation, hence future studies could focus on co-morbidity among patients who had had long-term DP before their first CABG or PCI.
Women were associated with both higher prevalent and incident DP in the studied
smaller coronary arteries than men and that the intervention procedures are still not optimal for women. Also, women’s higher sick-leave rate, other work arenas and demands, and possible other gender bias in health care could contribute to the higher DP rates in women.
These gender differences show the importance of conducting gender-specific studies on DP in this patient group, in order to gain knowledge on possible mechanisms in both women and men.
Many socio-demographic factors were associated with DP in relation to coronary
revascularisation at the time of intervention. Of these, several have also been associated with DP in the general population.
So far, only few studies have investigated the association between DP and mortality. In this thesis, the risk of both all-cause and cause-specific (CVD, musculoskeletal and mental diagnoses) five-year mortality was higher among patients on DP, compared with those not on DP at the time of intervention, also among most of the included subpopulations. These risks remained regardless of adjustments for socio-demographic and medical factors. Therefore, in future studies it would be justified to also include other factors such as employment status before intervention, severity of disease at the time of intervention, as well as other multi- or co-morbidity factors, in order to be able to more in detail explain these associations.
The scientific knowledge on the consequences of being on DP is limited. However, this thesis found a higher five-year mortality risk among patients in all studied DP-diagnostic groups (CVD, musculoskeletal and mental diagnoses) compared with those not on DP at the time of coronary revascularisation. Hence, the risk was also higher among DP diagnoses considered as non-lethal. This is in line with previous studies on DP in general and the risk of mortality.
Furthermore, the all-cause mortality-risk was markedly higher among mental DP diagnoses, than among no DP at the time of intervention; over three times higher among women with PCI. This in spite of adjustments for age, level of education and medical factors (indication for intervention, diabetes mellitus at the time of intervention, in-patient care in the five years before intervention, and re-intervention in the five years following intervention). To further explain these associations, future studies may regard other medical factors, for example:
history of other co-morbidity, such as, the second DP diagnosis, or the second diagnosis for in-patient care before intervention.
6 Acknowledgements
Many people have contributed to my work of this thesis. I express my genuine gratitude to all of you! Especially I give my sincerest thanks to the following:
Kristina Alexanderson, my main supervisor. I cannot thank you enough for the opportunity you gave me to become a doctoral student at the Division of Insurance Medicine. Thank you so much for introducing me into the important arena of sickness absence research, and for sharing your great knowledge, skills and essential support during this process. I am grateful for your belief in me.
Marjan Vaez, my co-supervisor. Thank you for being a great support during my doctoral journey, for all hours spent coaching me in data programming when I did not have the experience and for your sincerity and openness during this process. It has been a great pleasure to be your doctoral student.
Margaretha Voss, my co-supervisor. Thank you for your support, especially during the first year of my doctoral studies when I had so many questions and so much to learn about
epidemiology and statistical methods. It has been a great pleasure to have gotten to know you.
My sincere gratefulness goes to my other co-authors Torbjörn Ivert, Kenneth Pehrsson and Niklas Hammar. Your deep knowledge on this medical and epidemiological arena has been essential in this thesis. Especially I thank Torbjörn Ivert for your fantastic support in many ways and for inviting me to see how the two studied interventions were performed in clinical practise.
A warm greeting goes to all colleagues at The Division of Insurance Medicine. What would I have done without you! I always feel relaxed and joyful when I come to work, and that is because I have such great co-workers. I am especially grateful for all the input I received from my opponents at the seminars of my four manuscripts, and of the “kappa”: Staffan Marklund, Åsa Samuelsson, Jurgita Narusyte, Michael Wiberg, Klas Gustafsson, Ellenor Mittendorfer-Rutz, and Mo Wang. Moreover, I would like to thank the statisticians Linnea Kjeldgård and Elin Hinas for answering all my statistical questions about SPSS.
Annika Evolahti and Katarina Lönnqvist, you are such an important part of this Division.
Thank you for your irreplaceable administration skills and Annika for your contribution regarding the language check of my “kappa”.
My informal mentors and ”bollplank” through all these years : Anna Löfgren-Wiltheus, Åsa Samuelsson, Marie Nilsson, Emilie Friberg, Linnea Kjeldgård, Elin Hinas, and my roommate Lisa Mather. What would the Doctoral Student life be without our debates about recipes, epidemiology, physical activity, philosophy, children and lots of fika?!
My deep thanks go out to the Doctoral School in Health Care Sciences (NFV), at Karolinska Institutet, for giving me the financial opportunity to become a doctoral student. I am grateful for all the courses, seminars and guidance that you have provided me with during these years.
My special thanks go to Lena von Koch, Anders Gustavsson, Inger Tjergefors, and Anders Kottorp. In addition, I want to thank all my PhD. candidate colleagues in HK-10, especially, Anna Jervaeus for being a great support during the first year of my studies, and for your friendship.
The project was also financially supported by different grants from the Swedish Research Council for Health, Working Life and Welfare.
I am also thankful for all the insights I got as a doctoral student representative in the steering group for the National School of Research in Caring Science, and in The Docent Committee of Karolinska Institutet. Therefore I want to send my gratitude to the people I have gotten to know in this context, in particularly: Lena von Koch, Anders Gustavsson, Inger Tjergefors, Anders Kottorp, Jan Ygge, and Inger Janninger.
My dear friends Therese, Anna L, Frideli, Lottski, Roberto, Maria, Anna P, Teresa, and Helena, thank you for bringing so much joy and movement into my life when it is needed the most. You balance my life!
The family Damström Thakker, thank you for being a great lovely family, for supporting us with great love, food and good times! And of course, for always being there for Alvar, and taking care of him when both Janak and I needed to work.
Mormor och Morfar, ni har varit med mig hela mitt liv. Tack för er kärlek, trygghet och alla mina fina barndomsminnen från landet.
Therese, min fina syster, men också min bästa vän. Tack för all inspiration, lyhördhet, härlig humor, och kärlek som du givit och ger mig!
Min pappa, Tack för allt du är: berättelserna, utmaningarna, idéerna, maten, bilderna, musiken. Du är en stor del av den jag är och anledningen till att jag ens började min akademiska resa.
Janak, min kärlek. Du skall få min doktorshatt! Med din värme, omsorg och uppriktighet känner jag mig alltid älskad, trygg, och stolt. Livet är så mycket mer tillsammans med dig.
Alvar, min strålande, busiga, kloka son. Du som kom in i våra liv mitt upp i allt doktorerande.
Med dig har jag perspektiv på det viktiga i livet. Älskar dig bortom all oändlighet!
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