Resumption of Work After Acute Coronary Syndrome or Coronary Artery Bypass Graft Surgery

Factors That Predict Early Return to Work After Myocardial Infarction: Importance of Coworker Support

Aim    Myocardial infarction (MI) affects the working-age group and cause many absences and lost days of work. Some occupational factors effect in the prognosis of MI patients. The objective of this study was to determine predictors of early, late and no return to work (RTW) after MI.Material and methods    In this cohort study, 240 pre-employed, male patients with MI from April 2020 through February 2022 provided data about their demographic, occupational, psychosocial, and medical information. Data was also collected about the treatment they received as patients, their feelings about socioeconomic support, and RTW time. RTW within two weeks after MI was defined as early RTW. The relationships of these variables and with early RTW and with late or no RTW were analyzed.Results    Ninety-four patients (39.6 %) returned to work within two weeks after MI, whereas 207 patients (87.3 %) returned to work by the end of six months. Many variables, including coworker support, were associated with early RTW in a univariate analysis. Regression analysis revealed that age, coworker support, marital status, the patient's own estimated RTW time, the number of the vessels with occlusion, and comorbidity were predictors of early RTW. Of these factors, only coworker support would be subject to modification.Conclusions    This study indicates that improving support from coworkers can increase early RTW after MI.

Adaptation and validation of the cardiovascular version of the Return-to-Work Obstacles and Self-Efficacy Scale (ROSES-CVD) to the Italian context

PURPOSE

Effective cardiac rehabilitation interventions must provide adequate support to overcome psychosocial return-to-work (RTW) barriers. No validated instrument is available for this aim for cardiovascular patients. The Return-to-work Obstacles and Self-Efficacy Scale (ROSES) measures RTW obstacles workers perceive and the self-efficacy for overcoming them through 46 items and ten dimensions. This study aimed to adapt and validate ROSES for cardiovascular disease (CVD) in the Italian context.

METHODS

This prospective study involved 183 CVD working patients at baseline and 121 six months later. ROSES-CVD internal consistency, construct, and predictive validity was evaluated with Cronbach's α, Confirmatory factor analyses (CFA), and ANCOVAs.

RESULTS

CFAs adequately replicated the original ROSES model (CFI = .92-.96; TLI = .91-.94; RMSEA = .042-.057; SRMR = .046-.071) with α close or higher than .70 for all dimensions. Four ROSES-CVD dimensions significantly predicted the number of days to RTW controlling for age, gender, educational level, and surgery type. Workers who perceived salient RTW obstacles and low self-efficacy in any of these dimensions in mean returned to work from 38 to 53 days later.

CONCLUSIONS

The study supported the validity and reliability of ROSES-CVD. This tool can be used in rehabilitation to detect CVD patients at risk of a longer RTW process and define appropriate cardiac rehabilitation intervention.IMPLICATIONS FOR REHABILITATIONVocational rehabilitation interventions should provide tailor-made support to overcome RTW barriers based on individual risk assessmentThe Italian translation of ROSES-CVD is a valid and reliable tool to measure psychosocial barriers to RTW among CVD working patientsThe use of ROSES-CVD would allow detection of CVD patients at risk of longer RTW processAdministering ROSES-CVD can help focus traditional vocational intervention on individually relevant obstacles to RTW.

Projecting the Health and Economic Burden of Cardiovascular Disease Among People with Type 2 Diabetes, 2022-2031

OBJECTIVE

The aim was to project the health and economic outcomes of cardiovascular disease (CVD) among people with type 2 diabetes from Australian public healthcare and societal perspectives over the next decade.

METHODS

A dynamic multistate model with yearly cycles was developed to project cardiovascular events among Australians with type 2 diabetes aged 40-89 years from 2022 to 2031. CVD risk (myocardial infarction [MI] and stroke) in the type 2 diabetes population was estimated using the 2013 pooled cohort equation, and recurrent cardiovascular event rates in the type 2 diabetes with established CVD population were obtained from the global Reduction of Atherothrombosis for Continued Health (REACH) registry. Costs and utilities were derived from published sources. Outcomes included fatal and non-fatal MI and stroke, years of life lived, quality-adjusted life years (QALYs), total healthcare costs, and total productivity losses. The annual discount rate was 5%, applied to outcomes and costs.

RESULTS

Between 2022 and 2031, a total of 83,618 non-fatal MIs (95% uncertainty interval [UI] 83,170-84,053) and 58,774 non-fatal strokes (95% UI 58,458-59,013) were projected. Total years of life lived and QALYs (discounted) were projected to be 9,549,487 (95% UI 9,416,423-9,654,043) and 6,632,897 (95% UI 5,065,606-7,591,679), respectively. Total healthcare costs and total lost productivity costs (discounted) were projected to be 9.59 billion Australian dollars (AU$) (95% UI 1.90-30.45 billion) and AU$9.07 billion (95% UI 663.53 million-33.19 billion), respectively.

CONCLUSIONS

CVD in people with type 2 diabetes will substantially impact the Australian healthcare system and society over the next decade. Future work to investigate different strategies to optimize the control of risk factors for the prevention and treatment of CVD in type 2 diabetes in Australia is warranted.

Cost-effectiveness and Return on Investment of a Nationwide Case-Finding Program for Familial Hypercholesterolemia in Children in the Netherlands

Importance

The Netherlands is one of the few countries that has a long-term history of active screening for familial hypercholesterolemia (FH), enabling health-economic analyses.

Objective

To investigate cost-effectiveness and the return on investment (ROI) of a nationwide cascade case-finding and preventive treatment program starting with identification of FH in children and treatment, from both a societal and health care perspective.

Design, Setting, and Participants

Cascade case-finding and early preventive treatment were modeled to simulate the progression of disease and costs of 10-year-olds suspected of having heterozygous FH over a lifetime. The model consisted of 3 health states: alive without coronary heart disease (CHD), alive with CHD, and deceased. Mendelian randomization analysis was used to quantify the risk of a first CHD event as a function of age and total lifetime exposure to low-density lipoprotein cholesterol. Cost-effectiveness was defined as €20 000 ($21 800) per QALYs (quality-adjusted life-years) gained, using incremental cost-effectiveness ratios (ICERs). All future benefits and costs were discounted annually by 1.5% and 4%, respectively.

Interventions

The study compared 2 strategies: (1) cascade screening and initiation of treatment with statins in children (mean age, 10 years) and (2) no screening, later detection, and treatment.

Main Outcomes and Measures

Outcome of interest included cost, detection, and successful treatment of FH in terms of life-years gained and QALYs. The clinical and cost outputs for each model in the 2 scenarios (early detection and treatment and later detection and treatment) were totaled to determine the overall cost-effectiveness and ROI attributed to implementation of the Dutch FH program.

Results

In this model constructed to simulate the progression of FH in 1000 hypothetical 10-year-olds, from a health care perspective, the program would gain 2.53 QALYs per person, at an additional cost of €23 365 ($25 468) (both discounted). These equated to an ICER of €9220 ($10 050) per QALY gained. From the societal perspective, the detection and treatment program were cost saving over a lifetime compared with no cascade screening for FH. The ROI for the detection and treatment program for FH in children was €8.37 ($9.12).

Conclusions and Relevance

The findings of this study suggest that the early detection and treatment program for FH in children may offer a good value for investment, being both health and cost saving. The findings and interpretations are conditional on assumptions inherent in the health economic model.

Projecting the incidence and costs of major cardiovascular and kidney complications of type 2 diabetes with widespread SGLT2i and GLP-1 RA use: a cost-effectiveness analysis

AIMS/HYPOTHESIS

Whether sodium-glucose co-transporter 2 inhibitors (SGLT2is) or glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are cost-effective based solely on their cardiovascular and kidney benefits is unknown. We projected the health and economic outcomes due to myocardial infarction (MI), stroke, heart failure (HF) and end-stage kidney disease (ESKD) among people with type 2 diabetes, with and without CVD, under scenarios of widespread use of these drugs.

METHODS

We designed a microsimulation model using real-world data that captured CVD and ESKD morbidity and mortality from 2020 to 2040. The populations and transition probabilities were derived by linking the Australian Diabetes Registry (1.1 million people with type 2 diabetes) to hospital admissions databases, the National Death Index and the ESKD Registry using data from 2010 to 2019. We modelled four interventions: increase in use of SGLT2is or GLP-1 RAs to 75% of the total population with type 2 diabetes, and increase in use of SGLT2is or GLP-1 RAs to 75% of the secondary prevention population (i.e. people with type 2 diabetes and prior CVD). All interventions were compared with current use of SGLT2is (20% of the total population) and GLP-1 RAs (5% of the total population). Outcomes of interest included quality-adjusted life years (QALYs), total costs (from the Australian public healthcare perspective) and the incremental cost-effectiveness ratio (ICER). We applied 5% annual discounting for health economic outcomes. The willingness-to-pay threshold was set at AU$28,000 per QALY gained.

RESULTS

The numbers of QALYs gained from 2020 to 2040 with increased SGLT2i and GLP-1 RA use in the total population (n=1.1 million in 2020; n=1.5 million in 2040) were 176,446 and 200,932, respectively, compared with current use. Net cost differences were AU$4.2 billion for SGLT2is and AU$20.2 billion for GLP-1 RAs, and the ICERs were AU$23,717 and AU$100,705 per QALY gained, respectively. In the secondary prevention population, the ICERs were AU$8878 for SGLT2is and AU$79,742 for GLP-1 RAs.

CONCLUSIONS/INTERPRETATION

At current prices, use of SGLT2is, but not GLP-1 RAs, would be cost-effective when considering only their cardiovascular and kidney disease benefits for people with type 2 diabetes.

Prevalence and determinants of return to work after various coronary events: meta-analysis of prospective studies

Return to work (RTW) after a coronary event remains a major concern. This systematic review and meta-analysis of prospective studies published between January 1988 and August 2020, aim to evaluate the prevalence of RTW after a coronary event (myocardial infarction, acute coronary syndrome, angina pectoris) and to assess the determinants of RTW (such as follow-up duration, date of recruitment, country, gender, occupational factors, etc.). PRISMA and MOOSE guidelines were followed. Study quality was assessed using the Newcastle–Ottawa Scale. Random-effects models were carried out to determine pooled prevalence estimates and 95% confident interval. A total of 43 prospective studies (34,964 patients) were investigated. RTW overall random effects pooled prevalence was estimated at 81.1% [95% CI 75.8–85.8]. Country, year of implementation or gender did not significantly modify the prevalence estimates. Lower level of education and degraded left ventricular ejection fraction decreased RTW prevalence estimates (respectively, 76.1% vs 85.6% and 65.3% vs 77.8%). RTW prevalence estimates were higher for white-collars (81.2% vs 65.0% for blue-collars) and people with low physical workload (78.3% vs 64.1% for elevated physical workload).Occupational physical constraints seem to have a negative role in RTW while psycho-logical factors at work are insufficiently investigated. A better understanding of the real-life working conditions influencing RTW would be useful to maintain coronary patients in the labor market.

Projected New-Onset Cardiovascular Disease by Socioeconomic Group in Australia

BACKGROUND

Socioeconomic status has an important effect on cardiovascular disease (CVD). Data on the economic implications of CVD by socioeconomic status are needed to inform healthcare planning.

OBJECTIVES

The aim of this study was to project new-onset CVD and related health economic outcomes in Australia by socioeconomic status from 2021 to 2030.

METHODS

A dynamic population model was built to project annual new-onset CVD by socioeconomic quintile in Australians aged 40-79 years from 2021 to 2030. Cardiovascular risk was estimated using the Pooled Cohort Equation (PCE) from Australian-specific data, stratified for each socioeconomic quintile. The model projected years of life lived, quality- adjusted life-years (QALYs), acute healthcare medical costs, and productivity losses due to new-onset CVD. All outcomes were discounted by 5% annually.

RESULTS

PCE estimates showed that 8.4% of people in the most disadvantaged quintile were at high risk of CVD, compared with 3.7% in the least disadvantaged quintile (p < 0.001). From 2021 to 2030, the model projected 32% more cardiovascular events in the most disadvantaged quintile compared with the least disadvantaged (127,070 in SE 1 vs. 96,222 in SE 5). Acute healthcare costs in the most disadvantaged quintile were Australian dollars (AU$) 183 million higher than the least disadvantaged, and the difference in productivity costs was AU$959 million. Removing the equity gap (by applying the cardiovascular risk from the least disadvantaged quintile to the whole population) would prevent 114,822 cardiovascular events and save AU$704 million of healthcare costs and AU$3844 million of lost earnings over the next 10 years.

CONCLUSION

Our results highlight the pressing need to implement primary prevention interventions to reduce cardiovascular health inequity. This model provides a platform to incorporate socioeconomic status into health economic models by estimating which interventions are likely to yield more benefits in each socioeconomic quintile.

Return to work after coronary artery bypass grafting and aortic valve replacement surgery: A scoping review

BACKGROUND

Coronary artery bypass grafting surgery and aortic valve replacement surgery are essential treatment options for people suffering from angina pectoris or aortic valve disease. Surgery aims to prolong life expectancy, improve quality of life, and facilitate participation in society for the individuals afflicted. The aim of this review was to explore the literature on work participation in patients following coronary artery bypass grafting or aortic valve replacement surgery, and to identify demographic and clinical characteristics associated with returning to work.

METHODS

A scoping review framework of Arksey and O'Malley was chosen. Four electronic databases: Medline, CINAHL, Embase, and Google Scholar were searched for studies in English, Swedish, Danish or Norwegian between January 1988 and January 2020. A blinded selection of articles was performed. The data were then charted and summarized by descriptive numerical analyses and categorized into themes.

RESULTS

Forty-five out of 432 articles were included in the final full-text analysis. Absence from work following coronary artery bypass graft grafting or aortic valve replacement surgery lasted on average 30 weeks, whereas 34% of the patients never returned to work. Being female, suffering from pre-existing depression, having limited secondary education, or low income were associated with decreased return to work rates. Previous employment was a decisive factor for returning to work after surgery. Data on return to work after aortic valve replacement were scarce.

CONCLUSIONS

A significant number of patients never return to work following coronary artery bypass grafting or aortic valve surgery, and the time interval until work return is longer than expected. Failure to resume work represents a threat to the patients' finances and quality of life. Nurses are in a unique position to assess work-related issues and have an active part in the multi-disciplinary facilitation of tailored occupational counselling after cardiac surgery.

Future burden of cardiovascular disease in Australia: impact on health and economic outcomes between 2020 and 2029

AIMS

To estimate the health and economic burden of new and established cardiovascular disease from 2020 to 2029 in Australia.

METHODS AND RESULTS

A two-stage multistate dynamic model was developed to predict the burden of the incident and prevalent cardiovascular disease, for Australians 40-90 years old from 2020 to 2029. The model captured morbidity, mortality, years of life lived, quality-adjusted life years, healthcare costs, and productivity losses. Cardiovascular risk for the primary prevention population was derived using Australian demographic data and the Pooled Cohort Equation. Risk for the secondary prevention population was derived from the REACH registry. Input data for costs and utilities were extracted from published sources. All outcomes were annually discounted by 5%. A number of sensitivity analyses were undertaken to test the robustness of the study. Between 2020 and 2029, the model estimates 377 754 fatal and 991 375 non-fatal cardiovascular events. By 2029, 1 061 756 Australians will have prevalent cardiovascular disease (CVD). The population accrued 8 815 271 [95% uncertainty interval (UI) 8 805 083-8 841 432] years of life lived with CVD and 5 876 975 (5 551 484-6 226 045) QALYs. The total healthcare costs of CVD were projected to exceed Australian dollars (AUD) 61.89 (61.79-88.66) billion, and productivity losses will account for AUD 78.75 (49.40-295.25) billion, driving the total cost to surpass AUD 140.65 (123.13-370.23) billion.

CONCLUSION

Cardiovascular disease in Australia has substantial impacts in terms of morbidity, mortality, and lost revenue to the healthcare system and the society. Our modelling provides important information for decision making in relation to the future burden of cardiovascular disease.

Efficacy of Smartphone-Based Secondary Preventive Strategies in Coronary Artery Disease

Background:

Cardiac rehabilitation programs provide a comprehensive framework for the institution of secondary preventive measures. Smartphone technology can provide a platform for the delivery of such programs and is a promising alternative to hospital-based services. However, there is limited evidence to date supporting this approach. Accordingly, we performed a systematic review and meta-analysis examining smartphone-based secondary prevention programs to traditional cardiac rehabilitation in patients with established coronary artery disease to ascertain the feasibility and effectiveness of these interventions.

Methods:

A systematic search of PubMed, MEDLINE, EMBASE, and the Cochrane Library was conducted. A meta-analysis was performed using a random-effects model with the outcomes of interest being 6-minute walk test (6MWT) distance, systolic blood pressure, low-density lipoprotein (LDL) cholesterol, and body mass index (BMI).

Results:

A total of 8 studies with 1120 patients across 5 countries were included in the quantitative analysis. Follow-up ranged from 6 weeks to 12 months. Five studies examined all patients post acute coronary syndrome, 2 studies examined only patients undergoing percutaneous coronary intervention, and 1 study examined all patients with a diagnosis of coronary artery disease, independent of intervention. Exercise capacity, as measured by the 6MWT, was significantly greater in the smartphone group (20.10 meters, 95% confidence interval [CI] 7.44-33.97; P < .001; I² = 45.58). There was no significant difference in BMI reduction, systolic blood pressure, or LDL cholesterol levels between groups (P value for all > .05).

Conclusion:

Publicly available smartphone-based cardiac rehabilitation programs are a convenient and easily disseminated intervention which show merit in exercise promotion in patients with established coronary artery disease. Further research is required to establish the clinical significance of recent findings favoring their use.

Employment status three years after percutaneous coronary intervention and predictors for being employed: A nationwide prospective cohort study

BACKGROUND

Vocational support is recommended for patients in cardiac rehabilitation (CR), as returning to work is important in patients social readjusting after an acute coronary event. Information is lacking on whether CR leads to higher long-term employment after percutaneous coronary intervention (PCI).

AIMS

The aims of this study were to determine employment status three years after PCI, to compare employment status between CR participants and CR non-participants and to assess predictors for employment.

METHODS

We included first-time PCI patients from the NorStent trial, who were of working age (<63 years; n = 2488) at a three-year follow-up. Employment status and CR participation were assessed using a self-report questionnaire. Propensity score method was used in comparing employment status of CR participants and CR non-participants.

RESULTS

Seventy per cent of participants who were <60 years of age at the index event were employed at follow-up and CR participation had no effect on employment status. Being male, living with a partner and attaining higher levels of education were associated with a higher chance of being employed, while being older, prior cardiovascular morbidity and smoking status were associated with lower chance of being employed at follow-up.

CONCLUSION

Because a significant number of working-age coronary heart disease patients are unemployed three years after coronary revascularization, updated incentives should be implemented to promote vocational support. Such programmes should focus on females, patients lacking higher education and patients who are living alone, as they are more likely to remain unemployed.

Patients' expectations of returning to work, co-morbid disorders and work capacity at discharge from cardiac rehabilitation

Objective

We aimed to characterize patients after an acute cardiac event regarding their negative expectations around returning to work and the impact on work capacity upon discharge from cardiac rehabilitation (CR).

Methods

We analyzed routine data of 884 patients (52±7 years, 76% men) who attended 3 weeks of inpatient CR after an acute coronary syndrome (ACS) or cardiac surgery between October 2013 and March 2015. The primary outcome was their status determining their capacity to work (fit vs unfit) at discharge from CR. Further, sociodemographic data (eg, age, sex, and education level), diagnoses, functional data (eg, exercise stress test and 6-min walking test [6MWT]), the Hospital Anxiety and Depression Scale (HADS) and self-assessment of the occupational prognosis (negative expectations and/or unemployment, Würzburger screening) at admission to CR were considered.

Results

A negative occupational prognosis was detected in 384 patients (43%). Out of these, 368 (96%) expected not to return to work after CR and/or were unemployed before CR at 29% (n=113). Affected patients showed a reduced exercise capacity (bicycle stress test: 100 W vs 118 W, P<0.01; 6MWT: 380 m vs 421 m, P<0.01) and were more likely to receive a depression diagnosis (12% vs 3%, P<0.01), as well as higher levels on the HADS. At discharge from CR, 21% of this group (n=81) were fit for work (vs 35% of patients with a normal occupational prognosis (n=175, P<0.01)). Sick leave before the cardiac event (OR 0.4, 95% CI 0.2–0.6, P<0.01), negative occupational expectations (OR 0.4, 95% CI 0.3–0.7, P<0.01) and depression (OR 0.3, 95% CI 0.1–0.8, P=0.01) reduced the likelihood of achieving work capacity upon discharge. In contrast, higher exercise capacity was positively associated.

Conclusion

Patients with a negative occupational prognosis often revealed a reduced physical performance and suffered from a high psychosocial burden. In addition, patients’ occupational expectations were a predictor of work capacity at discharge from CR. Affected patients should be identified at admission to allow for targeted psychosocial care.

Determinants of Return to Work After Multicomponent Cardiac Rehabilitation

OBJECTIVES

To explore predictors of return to work in patients after acute coronary syndrome and coronary artery bypass grafting, taking into account cognitive performance, depression, physical capacity, and self-assessment of the occupational prognosis.

DESIGN

Observational, prospective, bicentric.

SETTING

Postacute 3-week inpatient cardiac rehabilitation (CR).

PARTICIPANTS

Patients (N=401) <65 years of age (mean 54.5±6.3y), 80% men.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Status of return to work (RTW) 6 months after discharge from CR.

RESULTS

The regression model for RTW showed negative associations for depression (odds ratio 0.52 per SD, 95% confidence interval 0.36-0.76, P=.001), age (odds ratio 0.72, 95% confidence interval 0.52-1.00, P=.047), and in particular for a negative subjective occupational prognosis (expected incapacity for work odds ratio 0.19, 95% confidence interval 0.06-0.59, P=.004; unemployment odds ratio 0.08, 95% confidence interval 0.01-0.72, P=.024; retirement odds ratio 0.07, 95% confidence interval 0.01-0.067, P=.021). Positive predictors were employment before the cardiac event (odds ratio 9.66, 95% confidence interval 3.10-30.12, P<.001), capacity to work (fit vs unfit) at discharge from CR (odds ratio 3.15, 95% confidence interval 1.35-7.35, P=.008), and maximum exercise capacity (odds ratio 1.49, 95% confidence interval 1.06-2.11, P=.022). Cognitive performance had no effect.

CONCLUSIONS

The patient's perception and expectation regarding the occupational prognosis play a crucial role in predicting return to work 6 months after an acute cardiac event and CR. These findings highlight the importance of the multimodal approach, in particular psychosocial components, of CR.

The importance of return to work: How to achieve optimal reintegration in ACS patients

The vocational reintegration of patients after an acute coronary syndrome is a crucial step towards complete convalescence from the social as well as the individual point of view. Return to work rates are determined by medical parameters such as left ventricular function, residual ischaemia and heart rhythm stability, as well as by occupational requirement profile such as blue or white collar work, night shifts and the ability to commute (which is, in part, determined by physical fitness). Psychosocial factors including depression, self-perceived health situation and pre-existing cognitive impairment determine the reintegration rate to a significant extent. Patients at risk of poor vocational outcomes should be identified in the early period of rehabilitation to avoid a reintegration failure and to prevent socio-professional exclusion with adverse psychological and financial consequences. A comprehensive healthcare pathway of acute coronary syndrome patients is initiated by cardiac rehabilitation, which includes specific algorithms and assessment tools for risk stratification and occupational restitution. As the first in its kind, this review addresses determinants and legal aspects of reintegration of patients experiencing an acute coronary syndrome, and offers practical advice on reintegration strategies particularly for vulnerable patients. It presents different approaches and scientific findings in the European countries and serves as a recommendation for action.

Predicting return to work after acute myocardial infarction: Socio-occupational factors overcome clinical conditions

Objectives

Return to work after acute myocardial infarction (AMI), a leading cause of death globally, is a multidimensional process influenced by clinical, psychological, social and occupational factors, the single impact of which, however, is still not well defined. The objective of this study was to investigate these 4 factors on return to work (RTW) within 365 days after AMI in a homogeneous cohort of patients who had undergone an urgent coronary angioplasty.

Participants

We studied 102 patients, in employment at the time of AMI (88.24% of men), admitted to the Department of Cardiology of the University-Hospital of Ferrara between March 2015 to December 2016. Demographical and clinical characteristics were obtained from the cardiological records. After completing an interview on social and occupational variables and the Hospital Anxiety and Depression (HADS) questionnaire, patients underwent exercise capacity measurement and spirometry.

Results

Of the 102 patients, only 12 (12.76%) held a university degree, 68.63% were employees and 31.37% self-employed. The median number of sick-leave days was 44 (IQR 33–88). At day 30, 78.5% of all subjects had not returned to work, at day 60, 40.8% and at day 365 only 7.3% had not resumed working. At univariate analyses, educational degree (p = 0.026), self-employment status (p = 0.0005), white collar professional category (p = 0.020) and HADS depression score were significant for earlier return to work. The multivariate analysis confirms that having a university degree, being self-employed and presenting a lower value of HADS depression score increase the probability of a quicker return to work.

Conclusions

These findings suggest that the strongest predictors of returning to work within 1 year after discharge for an acute myocardial infarction are related more to socio-occupational than to clinical parameters.

[Sense of Coherence Scale according to Antonovsky as a possible predictor for return to work for cardiac surgery intensive care patients]

BACKGROUND

For cardiac surgery patients who were employed prior to surgery, the return to their professional life is of special importance. In addition to medical reasons, such as pre-existing conditions, the success of the operation or postoperative course and patient-intrinsic reasons, which can be assessed with the Sense of Coherence (SOC) scale by Antonovsky, may also play a role in the question of a possible return into working life.

METHODS

In this study 278 patients (invasive coronary artery bypass graft surgery and/or surgery on heart valves, age < 60 years, employed) were questioned postoperatively via post with the SOC questionnaire. The SOC questionnaire was used in addition to questions about return to work. The cohort was stratified according to the time of return to work. Subsequently, the point of maximum sensitivity and specificity was determined for the total SOC score and the prediction power was considered.

RESULTS

Of the 278 patients, 61 questionnaires (22%) were considered as eligible and included in the analysis. Of these, 47 participants had returned to work after undergoing cardiac surgery and 14 participants had not. We observed significant differences in SOC values between both groups (146.07 ± 29.76 versus 124.29 ± 28.8, p = 0.020). Patients that returned to work within the first 6 months after surgery showed even higher SOC scores (148.56 ± 28.98, p = 0.034).

CONCLUSION

Patients with an SOC score < 130 are at greater risk not to return to their professional life after cardiac surgery. The SOC is an easily obtainable score that reliably predicts the probability of return to work after cardiac surgery.

{Health and work after invasive heart procedures, rehabilitation and occupational evaluation]

«Health and work after invasive heart procedures, rehabilitation and occupational evaluation».

Predicting return to work following a cardiac event in Malaysia

BACKGROUND

Return to work is an important aspect for cardiac rehabilitation following a major cardiac event.

OBJECTIVE

The aim was to understand the local prevalence and factors associated with returning to work in Malaysia after a cardiac event.

METHODS

A cross sectional design was used. All patients attending the cardiac rehabilitation program after major cardiac event during an 11-months period (2011-2012) were included. Data relating to socio-demographic, work-related, risk factors and acute myocardial infarction were collected. The SF-36 questionnaire was used to assess quality of life. Regression analysis was used to determine the predicting factors to return to work.

RESULTS

A total of 398 files were screened, 112 respondents agreed to participate giving a response rate of 47.3%. The prevalence of returned to work (RTW) was 66.1% [95% CI: 57.2-75.0]. Factors associated with work resumption were age (Adj. OR: 0.92 (95% CI: 0.84-0.99), diabetes mellitus (Adj. OR: 3.70, 95% CI: 1.35-10.12), Mental Component Summary (MCS) score (Adj. OR: 1.05 (95% CI: 1.01-1.09) and baseline angiography findings. Patients with single vessel and two vessel disease were 8.9 times and 3.78 times more likely to return to work compared to those with 3 vessels (Adj. OR: 8.90 (95% CI: 2.29-34.64) and Adj. OR: 3.78, (95% CI: 1.12, 12.74).

CONCLUSIONS

We proposed a cardiac rehabilitation program to emphasize mental health as it may improve successful return to work after cardiac event.

Costs of coronary heart disease and mortality associated with near-roadway air pollution

BACKGROUND

Emerging evidence indicates that the near-roadway air pollution (NRAP) mixture contributes to CHD, yet few studies have evaluated the associated costs.

OBJECTIVE

We integrated an assessment of NRAP-attributable CHD in Southern California with new methods to value the associated mortality and hospitalizations.

METHODS

Based on population-weighted residential exposure to NRAP (traffic density, proximity to a major roadway and elemental carbon), we estimated the inflation-adjusted value of NRAP-attributable mortality and costs of hospitalizations that occurred in 2008. We also estimated anticipated costs in 2035 based on projected changes in population and in NRAP exposure associated with California's plans to reduce greenhouse gas emissions. For comparison, we estimated the value of CHD mortality attributable to PM less than 2.5μm in diameter (PM2.5) in both 2008 and 2035.

RESULTS

The value of CHD mortality attributable to NRAP in 2008 was between $3.8 and $11.5 billion, 23% (major roadway proximity) to 68% (traffic density) of the $16.8 billion attributable to regulated regional PM2.5. NRAP-attributable costs were projected to increase to $10.6 to $22 billion in 2035, depending on the NRAP metric. Cost of NRAP-attributable hospitalizations for CHD in 2008 was $48.6 million and was projected to increase to $51.4 million in 2035.

CONCLUSIONS

We developed an economic framework that can be used to estimate the benefits of regulations to improve air quality. CHD attributable to NRAP has a large economic impact that is expected to increase by 2035, largely due to an aging population. PM2.5-attributable costs may underestimate total value of air pollution-attributable CHD.

[Returning to work after an acute coronary syndrome: When waiting is wasting]

BACKGROUND

Return to work (RTW) after acute coronary syndrome (ACS) is an important issue for the patient's future.

AIMS

The study aim was to determine whether RTW practice complies with guidelines or is delayed by failure in patient management. We analysed the factors influencing RTW beyond the 90-day period recommended by guidelines.

METHODS

We conducted a survey of 216 self-employed workers admitted to the hospital for ACS using self-report questionnaires and medical examination. Factors influencing RTW, occupational and cardiac features, and recall and source of medical information were investigated.

RESULTS

Ninety-three of 216 patients did not return to work by 90 days, despite good cardiac performance in 30 cases (32 %). The mean sick leave duration was 93.3±103.7 days. Advice concerning return to work was completely missing for 44 % of patients. Cardiac performance was independent of sick leave duration, but was correlated with the likelihood of RTW (P<0.001). Patients assimilated about 70 % of the medical information they were provided, but only 53 % of work-related information. Recall of work-related information was better among patients admitted to a rehabilitation facility (65 %) compared to those who did not receive rehabilitation (P<0.05).

CONCLUSION

Cardiologists should assess the patient's cardiac performance within 2 months after ACS. Patient management should also include cardiac rehabilitation or therapeutic education toward improving information recall.

Work stress and the risk of recurrent coronary heart disease events: A systematic review and meta-analysis

Though much evidence indicates that work stress increases the risk of incident of coronary heart disease (CHD), little is known about the role of work stress in the development of recurrent CHD events. The objective of this study was to review and synthesize the existing epidemiological evidence on whether work stress increases the risk of recurrent CHD events in patients with the first CHD. A systematic literature search in the PubMed database (January 1990 - December 2013) for prospective studies was performed. Inclusion criteria included: peer-reviewed English papers with original data, studies with substantial follow-up (> 3 years), end points defined as cardiac death or nonfatal myocardial infarction, as well as work stress assessed with reliable and valid instruments. Meta-analysis using random-effects modeling was conducted in order to synthesize the observed effects across the studies. Five papers derived from 4 prospective studies conducted in Sweden and Canada were included in this systematic review. The measurement of work stress was based on the Demand- Control model (4 papers) or the Effort-Reward Imbalance model (1 paper). According to the estimation by meta-analysis based on 4 papers, a significant effect of work stress on the risk of recurrent CHD events (hazard ratio: 1.65, 95% confidence interval: 1.23-2.22) was observed. Our findings suggest that, in patients with the first CHD, work stress is associated with an increased relative risk of recurrent CHD events by 65%. Due to the limited literature, more well-designed prospective research is needed to examine this association, in particular, from other than western regions of the world.

Productivity losses associated with cardiovascular disease: a systematic review

INTRODUCTION

People with cardiovascular disease (CVD) often require time off work to recover from illness or surgery; for example, following a myocardial infarction (MI) or stroke. These individuals incur income losses, work-related productivity is reduced for employers, and output is reduced for the wider economy. Productivity impacts to the economy also arise due to CVD-related mortality. Areas covered: A systematic literature review was conducted to identify and collate studies that report the magnitude of work-related productivity losses associated with CVD generally or specific cardiovascular (CV) events or conditions (coronary heart disease, MI, stroke, transient ischemic attack, angina, heart failure, peripheral artery disease, coronary revascularization). The search was conducted using Medline, Embase, the Cochrane Library, and Google to find studies published from January 2004 to January 2015. In total, 60 studies were identified, including 20 studies conducted in the USA, 25 studies conducted in Europe, and 18 studies conducted in other countries (three studies were conducted in multiple regions). The studies differed by the scope of losses assessed (absenteeism, presenteeism, early retirement, premature mortality) and CVD conditions/events included. Studies reported either average patient or population losses, and generally used a human capital rather than friction cost method. Outcomes were standardized and adjusted to 2015 US dollars where possible. Expert commentary: The review demonstrates that CVD imposes substantial morbidity- and mortality-related productivity costs. The studies identified in the review may be used to inform and populate societal economic evaluations in CVD, with the most appropriate source study being that most closely matching the context of the evaluation.

Employment Status and Sick Leave After First-Time Implantable Cardioverter Defibrillator Implantation: Results From the COPE-ICD Trial

BACKGROUND

In the Copenhagen Outpatient Programme-Implantable Cardioverter Defibrillator (COPE-ICD) Trial, a positive effect from a cost-saving, comprehensive cardiac rehabilitation program was found on physical and mental health in patients with ICDs.

OBJECTIVE

In the context of the COPE-ICD Trial, the aims of this study is to investigate (a) employment status after ICD implantation, (b) the number of sick days related to ICD implantation, (c) differences in employment status and sick days between rehabilitation and usual care groups, and (d) predictors of employment status and sick leave.

METHOD

Patients with first-time ICD implantation were randomized to comprehensive cardiac rehabilitation or usual care. One year after ICD implantation, patients answered questions about employment status and sick leave. Differences were tested using the Student t test and the χ test. Predictors of employment status and sick leave were tested using logistic regression and linear regression models.

RESULT

A total of 196 patients were randomized. The questionnaire was completed by 138 patients (70%). In total, 47% had worked before ICD implantation. After 1 year, 81% were still working and their mean (SD) number of sick days was 33.8 (58.3). Age 60 years or younger and secondary ICD indication were predictors of working after 1 year. Patients with secondary ICD indication had more sick days and patients who were not married had fewer sick days.

CONCLUSION

Most patients who worked before ICD implantation returned to work after the ICD was placed. Those who were married and had an ICD for secondary prevention took more sick days after the ICD than did those without these characteristics. Those who were younger and have a secondary indication ICD were more likely to be working 1 year after ICD implantation.

SMARTphone-based, early cardiac REHABilitation in patients with acute coronary syndromes [SMART-REHAB Trial]: a randomized controlled trial protocol

BACKGROUND

There are well-documented treatment gaps in secondary prevention of coronary heart disease and no clear guidelines to assist early physical activity after acute coronary syndromes (ACS). Smartphone technology may provide an innovative platform to close these gaps. This paper describes the study design of a randomized controlled trial assessing whether a smartphone-based secondary prevention program can facilitate early physical activity and improve cardiovascular health in patients with ACS.

METHODS

We have developed a multi-faceted, patient-centred smartphone-based secondary prevention program emphasizing early physical activity with a graduated walking program initiated on discharge from ACS admission. The program incorporates; physical activity tracking through the smartphone's accelerometer with interactive feedback and goal setting; a dynamic dashboard to review and optimize cardiovascular risk factors; educational messages delivered twice weekly; a photographic food diary; pharmacotherapy review; and support through a short message service. The primary endpoint of the trial is change in exercise capacity, as measured by the change in six-minute walk test distance at 8-weeks when compared to baseline. Secondary endpoints include improvements in cardiovascular risk factor status, psychological well-being and quality of life, medication adherence, uptake of cardiac rehabilitation and re-hospitalizations.

DISCUSSION

This randomized controlled trial will use a smartphone-phone based secondary prevention program to emphasize early physical activity post-ACS. It will provide evidence regarding the feasibility and utility of this innovative platform in closing the treatment gaps in secondary prevention.

TRIAL REGISTRATION

The trial was retrospectively registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) on April 4, 2016. The registration number is ACTRN12616000426482 .

Employment Status and Participation in Cardiac Rehabilitation: DOES ENCOURAGING EARLIER ENROLLMENT IMPROVE ATTENDANCE?

PURPOSE

For patients hospitalized for a cardiac event, an earlier appointment to outpatient cardiac rehabilitation (CR) increases participation. However, it is unknown what effect hastening CR enrollment might have among employed patients planning to return to work (RTW).

METHODS

Using 2 complementary data sets from Henry Ford Hospital (HFH) and Mayo Clinic, we assessed when employed patients eligible for CR anticipated a RTW, the impact of an earlier appointment on CR enrollment, and the effect of employment status on the number of CR sessions attended. Patients at HFH attended CR at either 8 or 42 days (through randomization), whereas Mayo Clinic patients attended 10 days after hospital discharge per standard routines.

RESULTS

Among 148 patients at HFH, 65 (44%) were employed and planned to RTW. Of these, 67% desired to RTW within 1 to 2 weeks, whereas 28% anticipated an RTW within 1 to 3 days. Home financial strain predicted nonparticipation in CR (P < .001) and was associated with an earlier planned RTW. Among 1030 patients at Mayo Clinic, 393 (38%) were employed. Employed (vs nonemployed) patients enrolled in CR 3.3 days sooner (P < .001), but attended 1.6 fewer CR sessions (P = .04). In employed patients from both health systems, an earlier (vs later) appointment to CR did not result in additional exercise sessions of CR.

CONCLUSIONS

Employed patients plan to RTW quickly, in part because of home finances. They also enroll earlier into CR than nonemployed patients. Despite these findings, earlier appointments do not seem to favorably impact overall CR participation.

Work stress and cardiovascular disease: a life course perspective

Individuals in employment experience stress at work, and numerous epidemiological studies have documented its negative health effects, particularly on cardiovascular disease (CVD). Although evidence on the various interrelationships between work stress and CVD has been accumulated, those observations have not yet been conceptualized in terms of a life course perspective. Using the chain of risk model, we would like to propose a theoretical model incorporating six steps: (1) work stress increases the risk of incident CVD in healthy workers. (2) Among those whose work ability is not fully and permanently damaged, work stress acts as a determinant of the process of return to work after CVD onset. (3) CVD patients experience higher work stress after return to work. (4) Work stress increases the risk of recurrent CVD in workers with prior CVD. (5) CVD patients who fully lose their work ability transit to disability retirement. (6) Disability retirees due to CVD have an elevated risk of CVD mortality. The life course perspective might facilitate an in-depth understanding of the diverse interrelationships between work stress and CVD, thereby leading to work stress management interventions at each period of the lifespan and three-level prevention of CVD.

Cardiopulmonary exercise testing is predictive of return to work in cardiac patients after multicomponent rehabilitation

BACKGROUND

Return to work (RTW) is a pivotal goal of cardiac rehabilitation (CR) in patients after acute cardiac event. We aimed to evaluate cardiopulmonary exercise testing (CPX) parameters as predictors for RTW at discharge after CR.

METHODS

We analyzed data from a registry of 489 working-age patients (51.5 ± 6.9 years, 87.9 % men) who had undergone inpatient CR predominantly after percutaneous coronary intervention (PCI 62.6 %), coronary artery bypass graft (CABG 17.2 %), or heart valve replacement (9.0 %). Sociodemographic and clinical parameters, noninvasive cardiac diagnostic (2D echo, exercise ECG, 6MWT) and psychodiagnostic screening data, as well as CPX findings, were merged with RTW data from the German statutory pension insurance program and analyzed for prognostic ability.

RESULTS

During a mean follow-up of 26.5 ± 11.9 months, 373 (76.3 %) patients returned to work, 116 (23.7 %) did not, and 60 (12.3 %) retired. After adjustment for covariates, elective CABG (HR 0.68, 95 % CI 0.47-0.98; p = 0.036) and work intensity (per level HR 0.83, 95 % CI 0.73-0.93; p = 0.002) were negatively associated with the probability of RTW. Exercise capacity in CPX (in Watts) and the VE/VCO2-slope had independent prognostic significance for RTW. A higher work load increased (HR 1.17, 95 % CI 1.02-1.35; p = 0.028) the probability of RTW, while a higher VE/VCO2 slope decreased (HR 0.85, 95 % CI 0.76-0.96; p = 0.009) it. CPX also had prognostic value for retirement: the likelihood of retirement decreased with increasing exercise capacity (HR 0.50, 95 % CI 0.30-0.82; p = 0.006).

CONCLUSION

CPX is a valid tool for assessing patients' ability to return to work. Therefore, it may be an essential part of functional assessment during CR for predicting participation in employment.

The Job Accommodation Scale (JAS): psychometric evaluation of a new measure of employer support for temporary job modifications

INTRODUCTION

An employer offer of temporary job modification is a key strategy for facilitating return-to-work for musculoskeletal conditions, but there are no validated scales to assess the level of support for temporary job modifications across a range of job types and organizations.

OBJECTIVE

To pilot test a new 21-item self-report measure [the Job Accommodation Scale (JAS)] to assess its applicability, internal consistency, factor structure, and relation to physical job demands.

METHODS

Supervisors (N = 804, 72.8 % male, mean age = 46) were recruited from 19 employment settings in the USA and Canada and completed a 30-min online survey regarding job modification practices. As part of the survey, supervisors nominated and described a job position they supervised and completed the JAS for a hypothetical worker (in that position) with an episode of low back pain. Job characteristics were derived from the occupational informational network job classification database.

RESULTS

The full response range (1-4) was utilized on all 21 items, with no ceiling or floor effects. Avoiding awkward postures was the most feasible accommodation and moving the employee to a different site or location was the least feasible. An exploratory factor analysis suggested five underlying factors (Modify physical workload; Modify work environment; Modify work schedule; Find alternate work; and Arrange for assistance), and there was an acceptable goodness-of-fit for the five parceled sub-factor scores as a single latent construct in a measurement model (structural equation model). Job accommodations were less feasible for more physical jobs and for heavier industries.

CONCLUSIONS

The pilot administration of the JAS with respect to a hypothetical worker with low back pain showed initial support for its applicability, reliability, and validity when administered to supervisors. Future studies should assess its validity for use in actual disability cases, for a range of health conditions, and to assess different stakeholder opinions about the feasibility of job accommodation strategies.