Interventions to support return to work for people with coronary heart disease New
People with coronary heart disease (CHD) often require prolonged absences from work to convalesce after acute disease events like myocardial infarctions (MI) or revascularisation procedures such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Reduced functional capacity and anxiety due to CHD may further delay or prevent return to work.
To assess the effects of person‐ and work‐directed interventions aimed at enhancing return to work in patients with coronary heart disease compared to usual care or no intervention.
We searched the databases CENTRAL, MEDLINE, Embase, PsycINFO, NIOSHTIC, NIOSHTIC‐2, HSELINE, CISDOC, and LILACS through 11 October 2018. We also searched the US National Library of Medicine registry, clinicaltrials.gov, to identify ongoing studies.
We included randomised controlled trials (RCTs) examining return to work among people with CHD who were provided either an intervention or usual care. Selected studies included only people treated for MI or who had undergone either a CABG or PCI. At least 80% of the study population should have been working prior to the CHD and not at the time of the trial, or study authors had to have considered a return‐to‐work subgroup. We included studies in all languages. Two review authors independently selected the studies and consulted a third review author to resolve disagreements.
Data collection and analysis
Two review authors extracted data and independently assessed the risk of bias. We conducted meta‐analyses of rates of return to work and time until return to work. We considered the secondary outcomes, health‐related quality of life and adverse events among studies where at least 80% of study participants were eligible to return to work.
We found 39 RCTs (including one cluster‐ and four three‐armed RCTs). We included the return‐to‐work results of 34 studies in the meta‐analyses.
Person‐directed, psychological counselling versus usual care
We included 11 studies considering return to work following psychological interventions among a subgroup of 615 participants in the meta‐analysis. Most interventions used some form of counselling to address participants' disease‐related anxieties and provided information on the causes and course of CHD to dispel misconceptions. We do not know if these interventions increase return to work up to six months (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.84 to 1.40; six studies; very low‐certainty evidence) or at six to 12 months (RR 1.24, 95% CI 0.95 to 1.63; seven studies; very low‐certainty evidence). We also do not know if psychological interventions shorten the time until return to work. Psychological interventions may have little or no effect on the proportion of participants working between one and five years (RR 1.09, 95% CI 0.88 to 1.34; three studies; low‐certainty evidence).
Person‐directed, work‐directed counselling versus usual care
Four studies examined work‐directed counselling. These counselling interventions included advising patients when to return to work based on treadmill testing or extended counselling to include co‐workers' fears and misconceptions regarding CHD. Work‐directed counselling may result in little to no difference in the mean difference (MD) in days until return to work (MD −7.52 days, 95% CI −20.07 to 5.03 days; four studies; low‐certainty evidence). Work‐directed counselling probably results in little to no difference in cardiac deaths (RR 1.00, 95% CI 0.19 to 5.39; two studies; moderate‐certainty evidence).
Person‐directed, physical conditioning interventions versus usual care
Nine studies examined the impact of exercise programmes. Compared to usual care, we do not know if physical interventions increase return to work up to six months (RR 1.17, 95% CI 0.97 to 1.41; four studies; very low‐certainty evidence). Physical conditioning interventions may result in little to no difference in return‐to‐work rates at six to 12 months (RR 1.09, 95% CI 0.99 to 1.20; five studies; low‐certainty evidence), and may also result in little to no difference on the rates of patients working after one year (RR 1.04, 95% CI 0.82 to 1.30; two studies; low‐certainty evidence). Physical conditioning interventions may result in little to no difference in the time needed to return to work (MD −7.86 days, 95% CI −29.46 to 13.74 days; four studies; low‐certainty evidence). Physical conditioning interventions probably do not increase cardiac death rates (RR 1.00, 95% CI 0.35 to 2.80; two studies; moderate‐certainty evidence).
Person‐directed, combined interventions versus usual care
We included 13 studies considering return to work following combined interventions in the meta‐analysis. Combined cardiac rehabilitation programmes may have increased return to work up to six months (RR 1.56, 95% CI 1.23 to 1.98; number needed to treat for an additional beneficial outcome (NNTB) 5; four studies; low‐certainty evidence), and may have little to no difference on return‐to‐work rates at six to 12 months' follow‐up (RR 1.06, 95% CI 1.00 to 1.13; 10 studies; low‐certainty evidence). We do not know if combined interventions increased the proportions of participants working between one and five years (RR 1.14, 95% CI 0.96 to 1.37; six studies; very low‐certainty evidence) or at five years (RR 1.09, 95% CI 0.86 to 1.38; four studies; very low‐certainty evidence). Combined interventions probably shortened the time needed until return to work (MD −40.77, 95% CI −67.19 to −14.35; two studies; moderate‐certainty evidence). Combining interventions probably results in little to no difference in reinfarctions (RR 0.56, 95% CI 0.23 to 1.40; three studies; moderate‐certainty evidence).
We found no studies exclusively examining strictly work‐directed interventions at the workplace.
Combined interventions may increase return to work up to six months and probably reduce the time away from work. Otherwise, we found no evidence of either a beneficial or harmful effect of person‐directed interventions. The certainty of the evidence for the various interventions and outcomes ranged from very low to moderate. Return to work was typically a secondary outcome of the studies, and as such, the results pertaining to return to work were often poorly reported. Adhering to RCT reporting guidelines could greatly improve the evidence of future research. A research gap exists regarding controlled trials of work‐directed interventions, health‐related quality of life within the return‐to‐work process, and adverse effects.
Janice Hegewald, Uta E Wegewitz, Ulrike Euler, Jaap L van Dijk, Jenny Adams, Alba Fishta, Philipp Heinrich, Andreas Seidler
Plain language summary
Interventions to help people return to work after a heart attack, bypass or stent.
What is the aim of this review?
We aimed to find and analyse the results of studies examining programmes to help people with heart disease return to work in order to determine if these programmes really help them return to work, and also if these programmes affect quality of life or have any unwanted effects.
Cardiac rehabilitation programmes, including both exercise and counselling components, probably shorten the time needed to return to work (moderate‐certainty evidence) and may increase the number of patients who return to work in the first six months after a heart attack, bypass or stent (low‐certainty evidence), but these programmes may have little or no effect on return to work after six months. Programmes comprising only counselling or exercise may make little to no difference in the number of patients returning to work or in the time needed to return to work (low to very low‐certainty evidence).
What was studied in the review?
People recovering from a heart attack or from a procedure to improve heart disease may have problems returning to work. These procedures could be a bypass (a surgical procedure to bypass narrowed coronary arteries, also called coronary artery bypass graft or CABG) or a nonsurgical intervention, including implanting stents (called percutaneous coronary interventions (PCI)), for example. Physical weakness and emotional problems resulting from heart disease may result in long absences from work or lead to disability retirement. Conditions at work may also make it difficult for patients to return to work. This can have a lasting impact on their quality of life. We looked at programmes that made it easier for people to return to work, for example by modifying their working conditions, or addressing the anxiety that often accompanies heart disease by educating patients on heart health, helping them to exercise or applying a combination of counselling and exercise to help them become healthy enough to return to work.
What are the main results of the review?
We found a total 39 studies that looked at return to work among people with heart disease in programmes designed to support the recovery process or encourage return to work compared to patients receiving usual care.
We found no studies that made changes to the workplace or workplace policies to ease the return to work, for example by reducing patients' working hours or tasks, and gradually increasing the working hours and tasks as health improves.
We found 11 studies evaluating programmes that addressed the fears and depression that often accompany heart disease, by teaching patients about heart disease. We do not know if these counselling and health education programmes increase the number of patients who returned to work or shorten the time patients are away from their jobs (low‐ to very low‐certainty evidence).
We found four studies using programmes that recommended when people with heart disease should return to work or provided counselling to co‐workers to address their concerns regarding the causes of the heart attacks and the patient’s ability to resume working. Work‐directed counselling interventions may make little to no difference to the time patients need to return to work (low‐certainty evidence).
We found nine studies providing exercise programmes alone. Exercise programmes may make little to no difference in the number of patients returning to work between six months and a year (low‐certainty evidence) and may make little to no difference in the number of patients working between one and five years or in the time needed to return to work (low‐certainty evidence).
We found 17 studies that evaluated combined exercise and counselling programmes. These combined programmes may increase the number of patients returning to work up to six months after a heart attack, bypass or stent (low‐certainty evidence): for every five patients enrolled in a combined cardiac rehabilitation programme, one additional patient may return to work. These programs probably shorten the time needed to return to work (moderate‐certainty evidence) by about a month.
How up‐to‐date is this review?
We searched for studies that had been published up to 11 October 2018.
Janice Hegewald, Uta E Wegewitz, Ulrike Euler, Jaap L van Dijk, Jenny Adams, Alba Fishta, Philipp Heinrich, Andreas Seidler
Implications for practice
We found low‐certainty evidence that cardiac rehabilitation, including both physical conditioning and psychological aspects, may promote return to work up to six months following coronary heart disease (CHD), but we also found low‐certainty evidence that these programmes may have little or no effect on the proportion of participants returning to work between six months and one year. Due to the very low certainty of evidence found, we do not know if these programmes increase the proportion of participants at work after a year.
Regarding single‐component, person‐directed interventions, we do not know if programmes including only a counselling component make any difference in return to work up to six months or between six months and one year (very low‐certainty evidence). We found low‐certainty evidence that work‐directed counselling alone may result in little to no difference in the time needed to return to work. We found very low‐certainty evidence regarding the effect of physical conditioning programmes up to six months, so we do not know if physical conditioning alone has any effect on return to work. Physical conditioning programmes may result in little to no difference in return to work between six months and one year (low‐certainty evidence).
Implications for research
Our review identified several aspects that future research could address.
In our analysis, pooling the effect estimates of psychological interventions (including health education) and physical conditioning interventions resulted in risk ratios 1.24 and 1.17, respectively, for short‐term return to work, but the pooled confidence intervals were imprecise. According to our power analysis, the pooled confidence intervals for these two results should not have included a null effect 83% to 84% of the time. To find precise estimates of smaller effects 80% of the time with 95% confidence, such as the RR 1.06 we observed for medium‐term return to work following combined interventions, new studies need to recruit altogether 3774 study participants (compared to the 992 study participants included in our analysis). Since sick leave is costly for employers and paid sick leave may be limited or even unavailable for some workers, we consider even small increases in return to work to be relevant. However, detecting small effects requires conducting very large trials.
In addition, we still need high quality studies that directly address the return‐to‐work process and adequately report the vocational status and job characteristics of study participants prior to the onset of CHD. In a subgroup analysis of physical conditioning interventions, we found that physical conditioning lowered the time needed to return to work only among the two study populations where physically strenuous working conditions or blue‐collar occupations were predominant (Analysis 3.4). More information is needed to corroborate this finding and to determine if interventions may be more effective at promoting return to work for certain employee populations.
When working situations are beneficial and supportive of health, return to work can be considered an important component of regaining full health and improving health‐related quality of life. Delayed return to work or early retirement following CHD can have long‐lasting detrimental financial consequences on individuals and their families, especially where social systems are lacking to provide adequate financial support following a prolonged illness. For some people, such financial factors may be the main impulse to decide if and when they will return to work. Additional research is needed to determine if health outcomes are comparable between people who feel compelled to return to work and those who want to return to work of their own accord.
Interventions and comparisons
Additional evidence is also needed to determine if cardiac rehabilitation including both physical conditioning and psychological components truly promotes return to work up to six months following CHD. In addition to containing exercise, as well as anxiety and risk factor education, future combined interventions may also need to develop better ways to assist transitions back into the workforce without inadvertently promoting presenteeism. Returning to work is a complex and multi‐factorial process, and combined interventions that better address work‐related factors, possibly by providing return‐to‐work coordination, could eliminate further barriers to returning to work. Cardiac rehabilitation interventions also need to make accommodations for people who have to or want to return to work. There is a need to concurrently support the recovery process while alleviating any difficulties that can occur during the return‐to‐work process. This may require the development of strategies that improve access to cardiac rehabilitation centres.
None of the studies exclusively considered work‐directed interventions such as stepwise occupational reintegration (SOR). We also found no controlled studies on the effectiveness of coaching by an occupational physician or on the effects of structured communication between occupational physicians, employers, and the cardiac rehabilitation team. Few combined rehabilitation programmes (three studies) mentioned providing individual work‐directed recommendations to patients or employers as part of the rehabilitation programme. Similarly, only a few studies directly addressed the return‐to‐work process by offering a recommendation for when to return to work (three studies) or by counselling patients and their co‐workers to assuage their concerns about working with heart disease (one study). Although studies sometimes reported changes in working status (full versus part time), reductions in working hours seemed to have been initiated by the patients themselves and were not part of the intervention.
In view of the variation of the single interventions implemented to address either physical or psychological condition following CHD, more research is also needed. Effective single interventions are advantageous, because they are cheaper and simpler to organise than the combined interventions and can also take place outside cardiac rehabilitation centres. Studies considering single components of combined interventions also help explain how much return to work is impacted by either focusing on psychological or physical recovery following CHD among study participants with specific risks.
Return to work was often a secondary outcome of the studies, and as such, the results pertaining to return to work were often poorly reported. Providing the complete results of secondary analyses, at least as on‐line supplements (even when the results were not statistically significant), would help future assessments of return to work among people with CHD. Adhering to recommended reporting guidelines for RCTs could also greatly improve the evidence obtained from future research of return to work following cardiac rehabilitation programmes.
A priori registration of protocols in online RCT registries, which would assist in the objective assessment of selective reporting, may already be improving, as we found seven ongoing registered studies. We also encountered difficulties in identifying participant populations with comparable CHD severity due to the greatly varying selection of cardiac health measures and comorbidities reported. Using core outcome sets when assessing cardiac health of study populations will help alleviate this problem.Get full text at The Cochrane Library
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