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PubMed1994

The evolving concept of the healthy worker survivor effect.

The "healthy worker survivor effect" describes a continuing selection process such that those who remain employed tend to be healthier than those who leave employment. In an analysis of exposure-response patterns in an occupational study, the healthy worker survivor effect generally attenuates an adverse effect of exposure. In practical terms, such attenuation will be more problematic when evaluating subtle rather than strong associations. The use of an internal referent does not guarantee elimination of this effect, since by definition, it manifests within an occupational cohort. Although documented over 100 years ago, there is little consensus regarding the most appropriate method to control for the healthy worker survivor effect. Four methods have been proposed for its control: (1) restriction of the cohort to survivors of a fixed number of years of follow-up, (2) lagging the exposure to exclude recent exposure incurred by those who remained on the job, (3) adjusting for employment status as a confounder, and (4) treating the healthy worker survivor effect simultaneously as an intermediate and confounding variable by means of the G-null test or its extension, G-estimation analysis, using structurally nested failure time models. This paper reviews the concept of the healthy worker survivor effect and the four methods to control for it.

Bias↗
PubMed1986

Mortality of medical practitioners in Japan: social class and the "healthy worker effect".

To assess patterns of mortality in Japanese medical practitioners, we compared the mortality of male physicians in a Japanese prefecture with that of eight major working populations, the nonworking population, and the general population of all Japan and of the prefecture. Standardized mortality ratios were calculated. All-causes mortality in medical practitioners aged 25-64 years was significantly higher than that of administrative and managing workers (standardized mortality ratio [SMR] = 228); it was significantly lower than that of the nonworking population (SMR = 23). Physicians were found to have higher cause-specific mortality for pneumonia and bronchitis and for ischemic heart disease than the total working population. These findings suggest that the previously reported low mortality of physicians reflects principally their high socioeconomic status; within the professional class, the mortality of medical practitioners compares unfavorably with that of other persons.

Adult↗
PubMed1987

Current mortality in the Australian petroleum industry: the healthy-worker effect and the influence of life-style factors.

A surveillance system, to monitor mortality and cancer morbidity on a continuing basis, has been established in the Australian petroleum industry. A baseline survey of 11,573 employees, by personal interview, was carried out in 1981-1983. By the end of June 1986, 33,712 person-years of observation in men had accrued, with 109 deaths. Standardized mortality ratios, with the Australian national death rates as reference, indicate that in terms of mortality from all causes and in mortality from the more common diseases, the death rates in this population are substantially lower than in the national population. Standardization was also carried out in the case of employed men, with data from contributors to the Commonwealth superannuation fund as reference, in order to provide a more appropriate contrast. The risks of tobacco smoking are demonstrated, as is the probable protective effect of mild-to-moderate alcohol consumption. The advantages to the occupational physician in being able to describe current mortality patterns, and in being able to delineate "at-risk" groups are discussed, particularly in the context of health promotion and other interventions.

Alcohol Drinking↗
PubMed1986

Extent, persistence, and constancy of the healthy worker or healthy person effect by all and selected causes of death.

Hypotheses about the extent, persistence, and constancy for different causes of the healthy worker effect are evaluated using the data of the Dorn Study of Mortality Among US Veterans. Those data were selected because persons who qualify to serve in the armed forces have health status comparable to that of persons able to seek employment. Mortality rates for 5-year age groups and standardized mortality ratios for younger, older, and all age groups were computed and compared to those of the US population for all causes, all cancers, heart disease, stroke, and selected other causes of death. A healthy worker effect of 20% to 40% reduced mortality was shown to persist over the entire age range for the various causes. The overall effect for all causes is 27%.

Adult↗
PubMedDate not supplied

Mortality in commercial fishermen of Atlantic Canada.

All commercial fishermen in the Canadian Maritime provinces (Nova Scotia, New Brunswick, and Prince Edward Island) are registered with the Department of Fisheries and Oceans (DFO). The data obtained by DFO during 1975-1983 on 33,000 fishermen were linked with the Canadian Mortality Data Base by the record linkage procedures in place at Statistics Canada, thus identifying 1,289 male deaths. When Canadian mortality rates were used to calculate the expected number of deaths, the standardized mortality ratio (SMR) was 0.80 for all causes. The rather low SMR can be explained at least partially by "the healthy worker effect". Although the healthy worker effect is generally greater for the younger age groups (i.e. a lower SMR), in this study the all-causes SMR for those under 44 years of age was 1.5. All accidents together showed an SMR of 1.5 which was even higher for the younger age groups (1.75). The most striking finding was the ratio for water transport accidents where observed deaths occurred at 8.5 times the expected rate. SMR for cancers were somewhat high, especially cancer of the pancreas at 1.5. Notable also were the very low rates for respiratory diseases although the younger fishermen still had an SMR greater than one. From a public health point of view, the high accident mortality for all fishermen and high mortality for many causes at the most productive ages associated with this occupation is of concern.

Accidents, Occupational↗
PubMed1999

Healthy volunteer effect in industrial workers.

Volunteers for epidemiological research, have lower mortality rates than non-volunteers, thereby producing a bias referred to as the "healthy volunteer effect" (HVE). Occupationally active persons have been similarly shown to have a reduced mortality relatively to the general population (the "healthy worker effect"). To determine whether a HVE exists in occupationally active persons, we followed for 8 years a cohort of Israeli male industrial employees, of whom 71.6% agreed to participate in 1985 in screening examinations for cardiovascular disease. We calculated standardized mortality ratios (SMRs) of the entire cohort relative to the general population, and compared the mortality among participants with that of the non-participants. Over 8 years follow up, SMRs were 78% for the entire cohort, 71% for participants and 99% for non-participants. Participants were older than non-participants and worked more commonly in smaller factories. A proportional hazard model indicated that after adjusting for these variables, the all cause mortality hazard ratio among participants and non-participants was 0.69 (95% CI = 0.51-0.94). During the first and last two years of the 8-year follow-up there were 39.6 and 30.0 age-adjusted deaths per 10,000 person-years among participants, and 58.6 and 51.5 respectively among non-participants. We conclude that the HVE occurs in occupationally active persons, and that it may persist for up to 8 years follow-up.

Adult↗
PubMed2000

Does arsenic exposure increase the risk for circulatory disease?

Studies of residents in communities with high endemic concentrations of arsenic in drinking water suggest a deleterious effect on the circulatory system; however, studies among workers with high occupational exposures generally have shown either no or weak associations. This discrepancy could be a result of the healthy worker effect, including the healthy hire component and the healthy worker survivor effect (HWSE). Therefore, the authors conducted analyses of arsenic exposure in relation to circulatory disease mortality among 2,802 Tacoma, Washington, smelter workers by using 1) internal comparisons to control for the healthy hire effect and 2) the lagging method, adjustment for employment status, and the G-null test to control for the HWSE. Both lagging and adjustment for work status increased circulatory mortality rate ratios at all exposure levels, as compared with a baseline Poisson model. This excess mortality was limited to cardiovascular disease; no excess was observed for cerebrovascular disease. G-null analyses suggested no adverse effect, but power was very limited for this analysis. Overall, these results may indicate that the HWSE obscures an effect of arsenic on circulatory disease. Since cardiovascular deaths constitute about one-third of total mortality, small rate ratios translate into large numbers of excess deaths and, if causal, could be of wide public health significance. Further studies of arsenic exposure and cardiovascular disease are needed, and those conducted in occupational cohorts must control for the HWSE.

Adult↗
PubMed2006

The healthy worker survivor effect in a study of neck muscle performance measures in call-centre operators.

BACKGROUND: The healthy worker survival effect is a complex and poorly controlled bias affecting occupational studies. Little is known about its behaviour in samples of computer based workers. This descriptive study examined the healthy worker effect in relation to muscle performance and neck pain in call-centre operators. METHODS: 28 call-centre workers were examined for postural muscle performance. Neck pain was measured using a validated questionnaire. Analysis was by multivariate regression of the cohort, stratified by years of employment. RESULTS: Analysis using the entire sample failed to display any relationship between neck pain and muscle performance. Further examination revealed survival/secondary selection within the sample, with pain and poor muscle performance reduced after 6 years employment. Stratified analysis demonstrated that deep flexor muscle performance and posture were statistically significantly associated with neck pain. Each stratum explained a greater percentage of the variance in questionnaire scores, increasing from 42.3% for the entire sample to 95.1% for the 4 years employed subgroup. CONCLUSION: The healthy worker survival effect is demonstrable in occupations with lower physical demands. It should be considered in analysis since it may obscure causal associations. There is no single method for controlling this bias and greater understanding of its components is required.

Adolescent↗
PubMed1996

Controlling the healthy worker survivor effect: an example of arsenic exposure and respiratory cancer.

OBJECTIVE: This investigation sought to examine whether methods proposed to control the healthy worker survivor effect would influence the shape or magnitude of the dose-response curve for respiratory cancer induced by arsenic. METHODS: Results from an unadjusted analysis are compared with results obtained by applying four different methods for control of the healthy worker survivor effect to data on arsenic exposure and respiratory cancer. The four methods are: exposure lag, adjustment for work status, cohort restriction, and the G null test. RESULTS: Cohort restriction gave erratic results depending upon the minimum years of follow up used. Exposure lag substantially increased the rate ratios and a non-linear shape (decreasing slope) compared with an unlagged analysis. Adjusting for work status (currently employed upsilon retired or otherwise not employed) yielded slightly higher rate ratios than an unadjusted analysis, with an overall shape similar to the baseline analysis. Results from the G null test procedure of Robins (1986), although not directly comparable with the baseline analysis, did show an adverse effect of exposure that seemed to reach a maximum when exposure was lagged between 10 and 20 years. CONCLUSIONS: All results confirm an adverse effect of arsenic exposure on respiratory cancer. In these data, it seems that the healthy worker survivor effect was not strong enough to mask the strong effect of arsenic exposure on respiratory cancer. Nevertheless, several methods show a stronger association between arsenic exposure and respiratory cancer after adjustment for the healthy worker survivor effect, suggesting that for weaker causal associations, studies not controlling for this source of bias will have low power to detect results. Although the G methods are theoretically the most unbiased, further work elucidating the validity of the assumptions underlying lagging, adjustment for work status, and the G methods are needed before clear recommendations can be made.

Aged↗