Association of Job Characteristics and Functional Impairments on Return to Work After ARDS

BackgroundJoblessness is common after ARDS, but related risk factors are not fully understood.Research QuestionWhat is the association between survivors' pre-ARDS workload and post-ARDS functional impairment, pain, and fatigue with their return to work (RTW) status?Study Design and MethodsThe U.S. Occupational Information Network (O∗NET) was used to determine pre-ARDS workload for participants in the ARDS Network Long-Term Outcomes Study (ALTOS). Post-ARDS functional impairment was assessed using the Mini-Mental State Examination and SF-36 Physical Functioning, Social Functioning, and Mental Health sub-scales, and categorized as either no impairments, only psychosocial impairment, physical with low psychosocial impairment, or physical with high psychosocial impairment. Post-ARDS pain and fatigue were assessed using the SF-36 pain item and Functional Assessment of Chronic Illness Therapy—Fatigue Scale fatigue scale, respectively. Generalized linear mixed modeling methods were used to evaluate associations among pre-ARDS workload, post-ARDS functional impairment, and symptoms of pain and fatigue with post-ARDS RTW.ResultsPre-ARDS workload was not associated with post-ARDS RTW. However, as compared with survivors with no functional impairment, those with only psychosocial impairment (OR [CI]: 0.18 [0.06-0.50]), as well as physical impairment plus either low psychosocial impairment (0.08 [0.03-0.22]) or high psychosocial impairment (0.01 [0.003-0.05]) had lower odds of working. Pain (0.06 [0.03-0.14]) and fatigue (0.07 [0.03-0.16]) were also negatively associated with RTW.InterpretationFor previously employed survivors of ARDS, post-ARDS psychosocial and physical impairments, pain, and fatigue were negatively associated with RTW, whereas pre-ARDS workload was not associated. These findings are important for designing and implementing vocational interventions for ARDS survivors. Joblessness is common after ARDS, but related risk factors are not fully understood. What is the association between survivors' pre-ARDS workload and post-ARDS functional impairment, pain, and fatigue with their return to work (RTW) status? The U.S. Occupational Information Network (O∗NET) was used to determine pre-ARDS workload for participants in the ARDS Network Long-Term Outcomes Study (ALTOS). Post-ARDS functional impairment was assessed using the Mini-Mental State Examination and SF-36 Physical Functioning, Social Functioning, and Mental Health sub-scales, and categorized as either no impairments, only psychosocial impairment, physical with low psychosocial impairment, or physical with high psychosocial impairment. Post-ARDS pain and fatigue were assessed using the SF-36 pain item and Functional Assessment of Chronic Illness Therapy—Fatigue Scale fatigue scale, respectively. Generalized linear mixed modeling methods were used to evaluate associations among pre-ARDS workload, post-ARDS functional impairment, and symptoms of pain and fatigue with post-ARDS RTW. Pre-ARDS workload was not associated with post-ARDS RTW. However, as compared with survivors with no functional impairment, those with only psychosocial impairment (OR [CI]: 0.18 [0.06-0.50]), as well as physical impairment plus either low psychosocial impairment (0.08 [0.03-0.22]) or high psychosocial impairment (0.01 [0.003-0.05]) had lower odds of working. Pain (0.06 [0.03-0.14]) and fatigue (0.07 [0.03-0.16]) were also negatively associated with RTW. For previously employed survivors of ARDS, post-ARDS psychosocial and physical impairments, pain, and fatigue were negatively associated with RTW, whereas pre-ARDS workload was not associated. These findings are important for designing and implementing vocational interventions for ARDS survivors. After hospitalization, return to work (RTW) is important for previously employed patients and is positively associated with functional recovery and economic status.1Hodgson C.L. Haines K.J. Bailey M. et al.Predictors of return to work in survivors of critical illness.J Crit Care. 2018; 48: 21-25Crossref PubMed Scopus (7) Google Scholar However, previously employed survivors of ARDS who required intensive care commonly experience joblessness over 5-year follow-up (36%-68%).2Kamdar B.B. Minxuan H. Dinglas V.D. et al.Joblessness and lost earnings after acute respiratory distress syndrome in a 1-year national multicenter study.Am J Resp Crit Care Med. 2017; 196: 1012-1020Crossref PubMed Scopus (67) Google Scholar, 3Kamdar B.B. Suri R. Suchyta M.R. et al.Return to work after critical illness: a systematic review and meta-analysis.Thorax. 2020; 75: 17Crossref PubMed Scopus (50) Google Scholar, 4Su H. Dreesmann N.J. Hough C.L. Bridges E. Thompson H.J. Factors associated with employment outcome after critical illness: systematic review, meta-analysis, and meta-regression.J Adv Nurs. 2021 Feb; 77: 653-663Crossref PubMed Scopus (4) Google Scholar Hence, a greater understanding of occupational and patient factors associated with post-ARDS employment outcomes is urgently needed. Among ARDS survivors, existing patient and hospitalization factors associated with joblessness include older age, non-White race, chronic health conditions, prolonged mechanical ventilation, and longer ICU and hospital lengths of stay.2Kamdar B.B. Minxuan H. Dinglas V.D. et al.Joblessness and lost earnings after acute respiratory distress syndrome in a 1-year national multicenter study.Am J Resp Crit Care Med. 2017; 196: 1012-1020Crossref PubMed Scopus (67) Google Scholar,5Kamdar B.B. Sepulveda K.A. Chong A. et al.Return to work and lost earnings after acute respiratory distress syndrome: A 5-year prospective, longitudinal study of long-term survivors.Thorax. 2018; 73: 125-133Crossref PubMed Scopus (48) Google Scholar However, few studies have evaluated joblessness with ARDS survivors' post-hospitalization status, including aspects of their physical, cognitive, and mental health status.6Herridge M.S. Cheung A.M. Tansey C.M. et al.One-year outcomes in survivors of the acute respiratory distress syndrome.N Engl J Med. 2003; 348: 683-693Crossref PubMed Scopus (1526) Google Scholar,7Rothenhäusler H.B. Ehrentraut S. Stoll C. Schelling G. Kapfhammer H.P. The relationship between cognitive performance and employment and health status in long-term survivors of the acute respiratory distress syndrome: results of an exploratory study.Gen Hosp Psychiatry. 2001; 23: 90-96Crossref PubMed Scopus (209) Google Scholar In other patient populations, post-hospitalization joblessness is associated with pre-hospitalization workload (the minimal ability required to perform a specific job8Heerkens Y. Engels J. Kuiper C. Van der Gulden J. Oostendorp R. The use of the ICF to describe work related factors influencing the health of employees.Disabil Rehabil. 2004; 26: 1060-1066Crossref PubMed Scopus (89) Google Scholar), post-hospitalization functional impairment (eg, physical, psychological, interpersonal, and cognitive impairment), and symptoms (eg, pain and fatigue).9Fraser R. Machamer J. Temkin N. Dikmen S. Doctor J. Return to work in traumatic brain injury (TBI): A perspective on capacity for job complexity.J Vocat Rehabil. 2006; 25: 141-148Google Scholar, 10Cancelliere C. Donovan J. Stochkendahl M.J. et al.Factors affecting return to work after injury or illness: best evidence synthesis of systematic reviews.Chiropr Man Therap. 2016; 24 (32-32)Crossref PubMed Scopus (158) Google Scholar, 11Feuerstein M. Todd B.L. Moskowitz M.C. et al.Work in cancer survivors: a model for practice and research.J Cancer Surviv. 2010; 4: 415-437Crossref PubMed Scopus (191) Google Scholar, 12Schultz I.Z. Stowell A.W. Feuerstein M. Gatchel R.J. Models of return to work for musculoskeletal disorders.J Occup Rehabil. 2007; 17: 327-352Crossref PubMed Scopus (164) Google Scholar Applying these findings to ARDS survivors required a deeper evaluation to assist in designing vocational interventions. Hence, our primary objective was to evaluate the associations of (a) pre-ARDS job workload, (b) post-ARDS functional impairment, and symptoms of (c) pain and (d) fatigue with RTW at 6 and 12 months after ARDS. As an exploratory objective, we also examined the association of these factors, in combination, with RTW at 6 and 12 months. This evaluation was conducted as a secondary data analysis of the ARDS Network Long-Term Outcomes Study (ALTOS).13Dinglas V.D. Hopkins R.O. Wozniak A.W. et al.One-year outcomes of rosuvastatin versus placebo in sepsis-associated acute respiratory distress syndrome: prospective follow-up of SAILS randomised trial.Thorax. 2016; 71: 401-410Crossref PubMed Scopus (47) Google Scholar, 14Needham D.M. Dinglas V.D. Bienvenu O.J. et al.One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial.BMJ. 2013; 346: f1532Crossref PubMed Scopus (188) Google Scholar, 15Needham D.M. Colantuoni E. Dinglas V.D. et al.Rosuvastatin versus placebo for delirium in intensive care and subsequent cognitive impairment in patients with sepsis-associated acute respiratory distress syndrome: an ancillary study to a randomised controlled trial.Lancet Respir Med. 2016; 4: 203-212Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 16Needham D.M. Dinglas V.D. Morris P.E. et al.Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding: EDEN trial follow-up.Am J Respir Crit Care Med. 2013; 188: 567-576Crossref PubMed Scopus (172) Google Scholar ALTOS is prospective cohort study that evaluated 6- and 12-month outcomes of participants from randomized trials conducted by the National Institutes of Health ARDS Network. Participants were enrolled from 43 hospitals during the period of 2008 to 2014.17Matthay M.A. Brower R.G. Carson S. et al.Randomized, placebo-controlled clinical trial of an aerosolized beta(2)-agonist for treatment of acute lung injury.Am J Respir Crit Care Med. 2011; 184: 561-568Crossref PubMed Scopus (346) Google Scholar, 18Rice T.W. Wheeler A.P. Thompson B.T. et al.Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial.JAMA. 2012; 307: 795-803Crossref PubMed Scopus (601) Google Scholar, 19Rice T.W. Wheeler A.P. Thompson B.T. deBoisblanc B.P. Steingrub J. Rock P. Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury.JAMA. 2011; 306: 1574-1581Crossref PubMed Scopus (383) Google Scholar, 20Truwit J.D. Bernard G.R. Steingrub J. et al.Rosuvastatin for sepsis-associated acute respiratory distress syndrome.N Engl J Med. 2014; 370: 2191-2200Crossref PubMed Scopus (326) Google Scholar In prospective follow-up of participants, treatments from these trials did not have any impact on 6- and 12-month physical, cognitive, or mental health and quality of life outcomes.13Dinglas V.D. Hopkins R.O. Wozniak A.W. et al.One-year outcomes of rosuvastatin versus placebo in sepsis-associated acute respiratory distress syndrome: prospective follow-up of SAILS randomised trial.Thorax. 2016; 71: 401-410Crossref PubMed Scopus (47) Google Scholar, 14Needham D.M. Dinglas V.D. Bienvenu O.J. et al.One year outcomes in patients with acute lung injury randomised to initial trophic or full enteral feeding: prospective follow-up of EDEN randomised trial.BMJ. 2013; 346: f1532Crossref PubMed Scopus (188) Google Scholar, 15Needham D.M. Colantuoni E. Dinglas V.D. et al.Rosuvastatin versus placebo for delirium in intensive care and subsequent cognitive impairment in patients with sepsis-associated acute respiratory distress syndrome: an ancillary study to a randomised controlled trial.Lancet Respir Med. 2016; 4: 203-212Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 16Needham D.M. Dinglas V.D. Morris P.E. et al.Physical and cognitive performance of patients with acute lung injury 1 year after initial trophic versus full enteral feeding: EDEN trial follow-up.Am J Respir Crit Care Med. 2013; 188: 567-576Crossref PubMed Scopus (172) Google Scholar For this analysis, participants in the ARDS Network parent studies were excluded if they (1) reported no employment before hospitalization for ARDS; (2) died or retired during the follow-up period; (3) had incomplete functional assessments; or (4) were missing employment outcome data during follow-up. As required to associate specific jobs with employment workload, we also excluded survivors who had a job title that: (1) could not be matched within the Occupational Information Network (O∗NET) dataset (n = 2), or (2) was classified as having both low physical and psychosocial workloads (because of a sample size too small for meaningful statistical analysis [n = 4]). Approval for ALTOS was obtained from the institutional review boards of all participating study sites. We reported this analysis in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines.21Equator NetworkThe Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies.https://www.equator-network.org/reporting-guidelines/strobe/Google Scholar Demographic and ICU variables were collected in the parent study, including age, sex, race, ZIP Code, ethnicity, Acute Physiology and Chronic Health Evaluation III (APACHE III) severity of illness score,22Knaus W.A. Wagner D.P. Draper E.A. et al.The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults.Chest. 1991; 100: 1619-1636Abstract Full Text Full Text PDF PubMed Scopus (2921) Google Scholar duration of mechanical ventilation, and ICU and hospital lengths of stay (LOS). As a measure of socioeconomic status, pre-ARDS household income was estimated using publicly available ZIP Code data, as done previously for this studys.23Ruhl A.P. Huang M. Colantuoni E. et al.Healthcare utilization and costs in ARDS survivors: a 1-year longitudinal national US multicenter study.Intensive Care Med. 2017; 43: 980-991Crossref PubMed Scopus (45) Google Scholar In the parent study, a previously developed employment questionnaire2Kamdar B.B. Minxuan H. Dinglas V.D. et al.Joblessness and lost earnings after acute respiratory distress syndrome in a 1-year national multicenter study.Am J Resp Crit Care Med. 2017; 196: 1012-1020Crossref PubMed Scopus (67) Google Scholar,5Kamdar B.B. Sepulveda K.A. Chong A. et al.Return to work and lost earnings after acute respiratory distress syndrome: A 5-year prospective, longitudinal study of long-term survivors.Thorax. 2018; 73: 125-133Crossref PubMed Scopus (48) Google Scholar was administered to survivors (or their proxies) at 6 and 12 months after ARDS. This in-depth questionnaire included questions regarding pre-ARDS job title, working full-time before ARDS (Y/N), and current employment status (ie, working or not working). For statistical analysis, the primary outcome was evaluated at both 6 and 12 months, and modeled as a binary variable indicating whether the ARDS survivor was working vs not working at the respective time point. To estimate survivors' pre-ARDS workload, we matched their pre-ARDS job title from their ALTOS employment questionnaire2Kamdar B.B. Minxuan H. Dinglas V.D. et al.Joblessness and lost earnings after acute respiratory distress syndrome in a 1-year national multicenter study.Am J Resp Crit Care Med. 2017; 196: 1012-1020Crossref PubMed Scopus (67) Google Scholar,5Kamdar B.B. Sepulveda K.A. Chong A. et al.Return to work and lost earnings after acute respiratory distress syndrome: A 5-year prospective, longitudinal study of long-term survivors.Thorax. 2018; 73: 125-133Crossref PubMed Scopus (48) Google Scholar with the O∗NET system.24National Center for O∗NET Development. O∗NET Resource Center.www.onetcenter.orgGoogle Scholar O∗NET is a regularly updated US Department of Labor database that provides, in detail, specific domains (ie, abilities, interests, knowledge, skills, work activities, work context, and work values) of nearly 1,000 occupations. Each domain contains several standardized descriptors, on a 1 to 5 scale, with higher scores identifying attributes more vital for specific occupations. In our study, descriptor scores >2 indicated a high workload, as defined by O∗NET.25National Center for O∗NET Development. O∗NET OnLine.www.onetonline.org/help/online/scalesGoogle Scholar Because impairments in memory, attention, and executive function are frequently reported cognitive issues in ICU survivors,26Hopkins R.O. Brett S. Chronic neurocognitive effects of critical illness.Curr Opin Crit Care. 2005; 11: 369-375Crossref PubMed Scopus (47) Google Scholar we used the descriptors "memorization and complex problem-solving" to capture cognitive workload. Additionally, we used descriptors "level of competition" and "social perceptiveness" to capture survivors' emotional and interpersonal workload, respectively. We then collapsed cognitive, emotional, and interpersonal workloads into a single variable, psychosocial workload, to identify jobs that had a high level of demand in this area (range, 0-3, with a higher number indicating greater demands). Finally, we used the descriptor "performing general physical activities" to capture survivors' physical workload. Using these psychosocial and physical workload data, we defined three pre-ARDS workload phenotypes based on actual RTW patterns observed in ALTOS: (1) only high psychosocial workload (ie, an O∗NET descriptor score >2 in >1 of psychosocial category [ie, cognitive, emotional, or interpersonal]; eg, telemarketer or software developer), (2) high physical (descriptor score >2) and low psychosocial (descriptor score >2 in ≤1 category) workload (eg, custodian or grocery store clerk), and (3) high physical and psychosocial (descriptor score >2 in >1 category) workload (eg, nurse or basketball coach). Functional impairment, an outcome encompassing psychosocial impairment (comprising cognitive, emotional, and interpersonal impairment) and physical impairment, was measured at 6 and 12 months post-ARDS. More specifically, cognitive function was measured by the Mini-Mental State Examination,27Newkirk L.A. Kim J.M. Thompson J.M. Tinklenberg J.R. Yesavage J.A. Taylor J.L. Validation of a 26-point telephone version of the Mini-Mental State Examination.J Geriatr Psychiatry Neurol. 2004; 17: 81-87Crossref PubMed Scopus (106) Google Scholar with a score <24 indicating cognitive impairment.28Pfoh E.R. Chan K.S. Dinglas V.D. et al.Cognitive screening among acute respiratory failure survivors: a cross-sectional evaluation of the Mini-Mental State Examination.Crit Care. 2015; 19: 220Crossref PubMed Scopus (29) Google Scholar Emotional, interpersonal, and physical impairment were measured by Short Form 36 (SF-36) mental health, social functioning, and physical function subscales, respectively. Each normalized subscale ranges from 0 to 100 (mean [SD] = 50 [10]), with a higher score indicating better status,29Ware J. Kosinski M.A. Dewey J. How to score version 2 of the SF-36® Health Survey. QualityMetric Incorporated, Lincoln2000Google Scholar and emotional, interpersonal, and physical impairments, respectively, defined as mental health, social functioning, and physical functioning normalized scores ≤40 (≥1 SD lower). Using these variables, we defined four post-ARDS functional impairment phenotypes based on observed RTW patterns: (1) no functional impairment, (2) only psychosocial impairments, (3) physical and low psychosocial impairment, and (4) physical and high psychosocial impairment. Pain and fatigue symptoms were measured at 6 and 12 months post-ARDS. Pain was evaluated by the pain interference question of the SF-36. This question asks the individual to rate the extent to which pain interferes with normal work, with responses ranging from "Not at all," "A little bit," "Moderate," "Quite a bit," to "Extremely,"29Ware J. Kosinski M.A. Dewey J. How to score version 2 of the SF-36® Health Survey. QualityMetric Incorporated, Lincoln2000Google Scholar with responses of "Moderate" or higher defined as experiencing pain. Fatigue was measured by Functional Assessment of Chronic Illness Therapy- Fatigue Scale, which measures an individual's level of fatigue during their usual daily activities over the past week. A transformed score (range, 0-100) ≤68 was defined as experiencing fatigue.30Butt Z. Lai J.-S. Rao D. Heinemann A.W. Bill A. Cella D. Measurement of fatigue in cancer, stroke, and HIV using the Functional Assessment of Chronic Illness Therapy—Fatigue (FACIT-F) scale.J Psychosom Res. 2013; 74: 64-68Crossref PubMed Scopus (55) Google Scholar We summarized data using means and SDs for continuous variables, and proportions for categorical variables. We compared data using Student t tests for continuous variables, and χ2 or Fisher exact tests, as appropriate, for categorical variables. For the primary objective, we used a generalized linear mixed model with a random intercept to evaluate, separately, the cross-sectional association of each exposure factor (pre-ARDS workload phenotype, post-ARDS functional impairment phenotype, pain, and fatigue) with RTW. Furthermore, we used logistic regression to evaluate the associations of individual exposures at 6 months with RTW at 12 months. For the secondary objective, we included all factors (pre-ARDS workload phenotype, post-ARDS functional impairment phenotype, pain, and fatigue) in separate generalized linear mixed-model and logistic regression models, evaluating their cross-sectional and prospective association with RTW, respectively. The following covariates were included in all regression models, chosen a priori based on prior publications2Kamdar B.B. Minxuan H. Dinglas V.D. et al.Joblessness and lost earnings after acute respiratory distress syndrome in a 1-year national multicenter study.Am J Resp Crit Care Med. 2017; 196: 1012-1020Crossref PubMed Scopus (67) Google Scholar,5Kamdar B.B. Sepulveda K.A. Chong A. et al.Return to work and lost earnings after acute respiratory distress syndrome: A 5-year prospective, longitudinal study of long-term survivors.Thorax. 2018; 73: 125-133Crossref PubMed Scopus (48) Google Scholar: age, sex, race, APACHE III, and hospital LOS. Because socioeconomic status also may influence RTW, all models were adjusted for pre-ARDS estimated household income.23Ruhl A.P. Huang M. Colantuoni E. et al.Healthcare utilization and costs in ARDS survivors: a 1-year longitudinal national US multicenter study.Intensive Care Med. 2017; 43: 980-991Crossref PubMed Scopus (45) Google Scholar In all models, multicollinearity was evaluated using variance inflation factors and was not detected (ie, all variance inflation factors <10). All analyses were performed using STATA 16 statistical software (StataCorp). A two-sided P < .05 denoted statistical significance, with no adjustment for multiple comparisons. To address the potential impact of missing data on our primary analyses, we conducted sensitivity analyses using multiple imputation methods (e-Appendix 1). A total of 326 and 284 previously employed survivors, respectively, were included in our 6- and 12-month post-ARDS analyses (Fig 1). Demographic and ICU variables and employment situations are summarized in Table 1 and e-Table 1, respectively. There were no significant differences in demographic or ICU factors among survivors who did or did not meet inclusion criteria for the 6-month analysis. However, as compared with those included, survivors excluded from the 12-month analysis tended to have longer mechanical ventilation duration and ICU LOS (e-Table 2).Table 1Demographic and ICU Variables, by Employment Status at 6 and 12 Months After ARDSaData presented as No. (%) unless otherwise noted and may not add to 100% because of rounding.VariableWorking at 6 Mo (n = 171)Not Working at 6 Mo (n = 155)PbCalculated by Student t test for continuous variables and χ2 or Fisher exact tests, as appropriate, for categorical variables.Working at 12 Mo (n = 161)Not Working at 12 Mo (n = 123)PbCalculated by Student t test for continuous variables and χ2 or Fisher exact tests, as appropriate, for categorical variables.Demographic factorsAge, mean (SD), y44 (13)46 (12).1644 (12)47 (12).04Female69 (40)76 (49).1264 (40)61 (50).12White race143 (84)114 (74).03138 (86)87 (71).002Hispanic ethnicity12 (7)17 (11).2511 (7)13 (11).28Pre-ARDS estimated household income, mean (SD), in thousands of dollarscEstimated household income is based on ZIP code of residence.2255 (21)52 (1.7).0856 (21)51 (18).03ICU FactorsAPACHE III severity of illness84 (26)85 (27).7582 (25)85 (27).39ARDS primary risk factor: Pulmonary119 (70)102 (66).48106 (66)90 (73).20 Sepsis27(16)31 (20).3927 (17)19 (16).87 Others25 (15)25 (16).7628 (17)17 (14).51Mechanical ventilation, mean (SD) d9 (8)13 (12)<.0019 (9)12 (12).02ICU LOS, mean (SD) d12 (9)17 (12)<.00112 (9)15 (12).005Hospital LOS, mean (SD) d18 (11)27(17)<.00119 (13)24 (16).005Pre-ARDS WorkloaddPsychosocial workload combines cognitive, emotional, and interpersonal workload categories, with a job exhibiting low (<2 categories), or high (≥2 categories) number of these categories.High psychosocial workload only63 (37)57 (37).9962 (39)42 (34).45High physical & low psychosocial workload34 (20)38 (25).3528 (17)34 (28).04High physical & high psychosocial workload74 (43)60 (39).4371 (44)47 (39).39Functional Impairment after ARDSePsychosocial impairment combines cognitive, emotional, and interpersonal impairment categories, with survivors having impairments in low (<2 categories), or high (≥2 categories) number of these categories.No impairment99 (58)fAnalyzed using functional impairments, pain, and fatigue at 6 months.36 (23)fAnalyzed using functional impairments, pain, and fatigue at 6 months.<.001113 (71)gAnalyzed using functional impairments, pain, and fatigue at 12 months.21 (17)gAnalyzed using functional impairments, pain, and fatigue at 12 months.<.001Only psychosocial impairments30 (17)fAnalyzed using functional impairments, pain, and fatigue at 6 months.18 (12)fAnalyzed using functional impairments, pain, and fatigue at 6 months..1618 (11)gAnalyzed using functional impairments, pain, and fatigue at 12 months.24 (20)gAnalyzed using functional impairments, pain, and fatigue at 12 months..062Physical & low psychosocial impairment28 (16)fAnalyzed using functional impairments, pain, and fatigue at 6 months.50 (32)fAnalyzed using functional impairments, pain, and fatigue at 6 months..00124 (15)gAnalyzed using functional impairments, pain, and fatigue at 12 months.37 (30)gAnalyzed using functional impairments, pain, and fatigue at 12 months..002Physical & high psychosocial impairment14 (8)fAnalyzed using functional impairments, pain, and fatigue at 6 months.51 (33)fAnalyzed using functional impairments, pain, and fatigue at 6 months.<.0016 (4)gAnalyzed using functional impairments, pain, and fatigue at 12 months.41 (34)gAnalyzed using functional impairments, pain, and fatigue at 12 months.<.001Symptoms after ARDSPain33 (19)fAnalyzed using functional impairments, pain, and fatigue at 6 months.98 (63)fAnalyzed using functional impairments, pain, and fatigue at 6 months.<.00130 (19)gAnalyzed using functional impairments, pain, and fatigue at 12 months.67 (55)gAnalyzed using functional impairments, pain, and fatigue at 12 months.<.001Fatigue74 (44)fAnalyzed using functional impairments, pain, and fatigue at 6 months.126 (81)fAnalyzed using functional impairments, pain, and fatigue at 6 months.<.00161 (38)gAnalyzed using functional impairments, pain, and fatigue at 12 months.97 (85)gAnalyzed using functional impairments, pain, and fatigue at 12 months.<.001APACHE III = Acute Physiology and Chronic Health Evaluation III; LOS = length of stay.a Data presented as No. (%) unless otherwise noted and may not add to 100% because of rounding.b Calculated by Student t test for continuous variables and χ2 or Fisher exact tests, as appropriate, for categorical variables.c Estimated household income is based on ZIP code of residence.22Knaus W.A. Wagner D.P. Draper E.A. et al.The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults.Chest. 1991; 100: 1619-1636Abstract Full Text Full Text PDF PubMed Scopus (2921) Google Scholard Psychosocial workload combines cognitive, emotional, and interpersonal workload categories, with a job exhibiting low (<2 categories), or high (≥2 categories) number of these categories.e Psychosocial impairment combines cognitive, emotional, and interpersonal impairment categories, with survivors having impairments in low (<2 categories), or high (≥2 categories) number of these categories.f Analyzed using functional impairments, pain, and fatigue at 6 months.g Analyzed using functional impairments, pain, and fatigue at 12 months. Open table in a new tab APACHE III = Acute Physiology and Chronic Health Evaluation III; LOS = length of stay. At 6 and 12 months after ARDS, respectively, 171 (52%) and 161 (57%) previously employed survivors had returned to work, with 191 (59%) and 150 (53%) reporting impairments (ie, physical or psychosocial), 200 (61%) and 158 (56%) reporting fatigue, and 131 (40%) and 97 (34%) reporting pain (Table 1). Among survivors with psychosocial impairments, 33%, 54%, and 44% reported cognitive, emotional, and interpersonal impairments at 6 months, respectively, and 48%, 71%, and 33% reported these impairments at 12 months. Those who were not working tended to be older and non-White, with longer hospital and ICU LOS, mechanical ventilation duration, and reporting greater impairments (physical or psychosocial) and symptoms (fatigue or pain). In cross-sectional models involving individual exposure factors, post-ARDS functional impairments, pa