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.

Key messages

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.

Authors' conclusions: 

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.

Read the full abstract...
Background: 

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.

Objectives: 

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.

Search strategy: 

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.

Selection criteria: 

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.

Main results: 

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).

Work-directed, interventions

We found no studies exclusively examining strictly work-directed interventions at the workplace.

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