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HeartWise Autumn 2004
Sick leave in coronary artery
disease: a review of the literature
Professor Joep Perk
Summary
This review showed that most patients can return to work after
myocardial infarction (MI). Percutaneous coronary intervention
(PCI) is a less debilitating coronary artery intervention than
coronary artery bypass grafting (CABG). Hence, it contributes
towards more rapid return to work, although in the long run there
are no differences in sick leave. People at higher ages or with
physically demanding jobs return to work to a lesser degree. An
international comparison shows that the duration of sick leave
varies greatly and that there is no clear scientific evidence to provide
guidance as to the duration and degree of sickness absence.
Research on sick leave in cardiac patients is scarce in recent
years. Developments in acute coronary care should inspire
renewed scientific involvement in this area of research.
Introduction
Cardiovascular diseases (CVDs) represent the third most
common cause for long-term sickness absence in Sweden: 8% of
the disability pensions in 2001 and 6% of sickness absence.
There are no guidelines for the optimal duration and degree of
sick leave and there are no well-defined interventions for
reducing the duration or preventing disability pension.
Rehabilitation remains the responsibility of the individual
physician which, in practice, means broad variations in the type
and level of interventions. This article reviews the current
knowledge for the purpose of providing supportive information
to those helping the cardiac patient return to the labour market.
Coronary artery disease (CAD) is the most common cause of death
in Sweden. In the past decades, diagnostics and treatment, both with
coronary artery intervention and pharmaceuticals, have improved
greatly. These developments have contributed to a marked reduction in
premature death, to fewer patients of working age with heart disease-
related impairments and to the onset of disease at higher ages. Has this
trend influenced sick leave and sick-listing practices in Europe?
The search for studies was based on relevant literature
databases. Approximately 400 publications since 1975 addressing
sickness absence due to CAD were identified, which included
anginal chest pain, myocardial infarction (MI), chronic ischaemic
heart disease, heart failure and conditions following various types
of coronary artery interventions (CABG, PCI). Heart
transplantation was not included. Other CVDs, i.e. the other
groups in ICD10 ‘I10-I99’, have been excluded as very few studies
could be identified within the respective diagnostic areas. In
assessing the quality, we used the method recommended by the
Swedish Institute for the Assessment of Medical Technology (SBU).
Sick leave after MI
Fourteen studies were found to be of sufficient quality (see Table
1). Two studies describe outcomes during the first year following
infarction, six studies present predictors for return to work and
six studies describe the outcome of interventions aimed at
limiting sickness absence.
Outcome following MI
In a prospective cohort study, Herlitz et al7investigated all
patients aged <65 years with MI and who were employed part-
time or full-time prior to infarction: 37% had returned to full-
time work and 12% to part-time work one year post-MI. Higher
age and larger infarctions influenced the outcome negatively.
Boudrez et al,2in the city of Gent, Belgium, found that of all
men aged <60 years who had experienced MI, only a few were on
long-term sick leave due to heart disease. During the course of the
first year, 85% had returned to work.
Predictors for return to work
Maeland et al8,9 followed 249 MI patients aged <67 years for six
months following onset: 25% were still on sick leave. Social and
psychological factors negatively influenced the possibility of return
to work: high age, low education, residence (worse in rural areas),
stress at the workplace and anxiety, depression and poor self-
confidence during the period of care. Wiklund et al14 in a cohort
study of 201 male MI patients aged <60 years at work prior to MI
showed that patients’ motivation to return to work was the most
important predictive factor. Patients with physically demanding
jobs returned to work to a lesser degree than patients with lighter
jobs. The duration of sick leave averaged 16 weeks in this cohort.
More recently, similar findings have been reported: a study of
first MI patients from New Zealand found that 58% of the
patients were working after six months.10 The patients’
perception that the disease was an obstacle for returning to work
predicted longer sick leave. Soejima et al13 showed that 83% of
male Japanese MI patients were back at work after eight months.
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HeartWise Autumn 2004
Table 1. Studies included – myocardial infarction
Reference Aim Focus of study No. Mean age Type of sick Intervention Return-to- Results
and country distribution leave data work (%)
Bengtsson,1To study the outcome of a Infarction patients 87: 44 39–65 Number of sick-leave Combined cardiac 85 No significant difference
Sweden rehabilitation programme <65 years vs 43 days year 1, % RTW rehabilitation programme in RTW between rehab and
after MI control groups. On average 177 vs
172 full-time sick-leave days, 58 vs
98 part-time days
Boudrez,2RTW after MI in men All men <60 years 295 m: 57.5 y Data via mailed survey 60% participated in a 85 69% of all subjects RTW, 85% of
Belgium in a regional infarction 1991. Only RTW rehabilitation programme those who worked before MI.
register Few cases of remaining sick leave
Burgess,3US RCT of psychosocial Infarction patients who 180: 89 50.9±7.4 Number RTW 3–4 and Nursing-based psychosocial 88 vs 88 10% still sick listed after 13 months,
rehabilitation after MI worked at least 20 hours vs 91 13 months after MI. Per intervention no effect from intervention
/week before infarction cent moved to another
job and sick-listed
Dennis,4US RCT of targeted advice Infarction patients (men) 201: 102 49 and Detailed info on time, Early stress test and 91 vs 88 Shorter sick leave with targeted
based on cardiac stress <60, with uncomplicated vs 99 50±7 degree and type of targeted advice on advice to primary care: 51 vs 75
test in men after MI, worked before RTW 6 months after MI. sick-leave duration sick-leave days after MI. RTW:
uncomplicated MI Economic consequences to primary care 32% reduction which gave 2102
USD as extra income in
the study group
Froelicher,5 To compare two different All survivors <70 years 258: 84 vs 57.1 vs RTW 12 vs 24 weeks Physical exercise, 94 83% returned to work at 12 wk
US interventions after MI with MI 88 vs 86 55.6 vs after discharge vs physical exercise after MI, 94% after 24 weeks.
with standard treatment 56.3 + education vs No difference between groups
standard treatment
Hedbäck,6 To compare the outcome All patients <65 years 305: 148 57.3 vs Return at 1, 2 and Combined cardiac rehab 51.8 vs No difference after 1 year
Sweden of a rehabilitation admitted for acute MI vs 157 57.2 5 years after infarction -programme vs 27.4 (61.5 vs 56.5%) but after 2 years
programme after MI with standard treatment (64.9 vs 43.1%) and
standard treatment after 5 years
Herlitz,7Outcome of morbidity All patients admitted to 921 72, 16-98 Percentage RTW of total Standard medical 49 Under 65: 37% full-time, 12%
Sweden and RTW 1 year after MI a specific hospital for MI groups, and of groups treatment part-time. Age and infarction size
<65 years predicts RTW
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HeartWise Autumn 2004
Table 1. Cont’d
Reference Aim Focus of study No. Mean age Type of sick Intervention Return-to- Results
and country distribution leave data work (%)
Maeland,8RTW 6 months after Consecutive group patients 249 <67 RTW and sick leave 6 Standard medical 72.7 See below. Residence, age, education,
Norway infarction in relation to after infarction <67 years months after MI treatment stress at work and with complications
job before, demographic predict RTW
factors and disease severity
Maeland,9To study RTW 6 months Consecutive group patients 249 <67 RTW and sick leave Standard medical 72.7 73% RTW half a year after infarction,
Norway after infarction vs after infarction <67 years 6 months after MI treatment 25% remained sick listed. Perception,
psychological variables anxiety, depression at hospital
predictors for RTW
Petrie,10 RTW 6 months after Consecutive group patients 143 53.2±8.4 RTW and sick leave 3 Participation in a combined 58 40/105 RTW after 6 weeks, 76
New Zealand infarction in relation to after first infarction <65 and 6 months after rehabilitation programme after 6 months. The patient’s initial
patient’s perception and years MI perception of disease severity
participation in cardiac determines the prognosis
rehabilitation
Pilote,11 RCT of targeted advice Consecutive group patients 187: 50 vs Via mailed survey/ Early stress test and 91 vs 95 No difference after 6 mths, but more
US based on stress-EKG after infarction <60 years, 95 vs 92 51±6 vs 7 telephone: RTW 1,3 targeted advice on patients in intervention group to
in men after working before infarction and 6 months after sick-leave duration coronary intervention. Patients without
uncomplicated MI; infarction to primary care resid. ischaemia at work sooner (38
advice days) in intervention group than
standard treatment (65 days)
Smith,12 To study RTW 1 year Consecutive group 151 51.2±8 Via mailed survey/ Standard medical 72 Educational level, physical demands
US after infarction vs work patients after first telephone: RTW 4 treatment of job, perception of disease and
before, demographic infarction <70 years and 12 months economic motives mainly determine
factors and degree of after infarction RTW
severity of the disease
Soejima,13 To study RTW 8 months First-time MI, men 134 54.3 Via mailed survey Standard medical 82.9 Age, depression, perception of
Japan after MI in relation <65 years, in /telephone: treatment health, difficulty in managing stress
to psychological and full-time job previously RTW on average 8 but not infarction size determine RTW
clinical variables in Japan months after infarction
Wiklund,14 To study factors that Male patients <60 years, 201 <60 Via mailed survey/ Standard medical 75 Importance of psychological factors
Sweden predict RTW 2 and working before MI telephone: return-to-work treatment in RTW. Patients indicated causal
12 months after MI 2 and 12 months after MI association between work and MI
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HeartWise Autumn 2004
The prevalence of depression during the care period and worry
concerning one’s own health were predictive of lower return to
work. Smith et al12 found in a study from the US that individuals
with higher socioeconomic status had a greater chance of
returning to work: 72% of all patients returned to work, a higher
number in those with high socioeconomic status.
Interventions
Dennis et al4showed that advice from a cardiologist at a teaching
hospital to the patient’s family physician could shorten sickness
absence. The intervention group reported a shorter sick leave
duration (51 vs 75 days), representing an economic gain of US$2,102
per patient. This could not be reproduced when advice was provided
by a non-hospital-based cardiologist, probably because of the selected
low risk population; most returned to work within a short period.11
Studies of cardiac rehabilitation programmes have been published.
Bengtsson1could not show a reduction in sickness absence in the
study group: 73% in the study group and 75% in the control group
were at work one year following onset. Likewise, Hedbäck et al6did
not find any effect after the first year in comparison with a
consecutive study group and a control group (62% vs 57%), even
though regular contact was made with the workplace to reduce the
duration of sick leave. However, increasingly more individuals in the
control group were sick-listed, and at five year follow up significantly
more remained at work among the participants of the programme
(52% compared to 27% in the control group).
Froelicher et al5offered three alternatives for aftercare:
participation in an exercise group, exercise including counselling
or only standard aftercare. In this study from the US, only a few
were sick-listed and 94% returned to work after six months
regardless of the design of aftercare.
The review has shown that at least half of the patients
following MI can return to work within the first year. The
duration of sick leave is influenced mainly by psychological and
social factors such as depression or self-confidence, low
educational level, physically demanding work and dissatisfaction
at the workplace. The outcomes of aftercare programmes and
counselling are uncertain as regards return to work.
Sick leave following PCI or CABG (see Table 2)
Twenty-one relevant studies were identified in the area of sick
leave/return to work. As with MI studies, there are three main
groups: descriptive, predictive and interventional regarding both
type of coronary artery intervention and aftercare. In three studies,
the outcome is described during the first year following the
intervention, and six studies investigated the predictors for return
to work following the intervention. Seven studies compared the
results between patients after PCI or CABG, and four studies
described the outcome of rehabilitation programmes. One study
compared different strategies for an acute coronary syndrome.
Outcome after CABG/PCI
Two studies describe the outcome following surgery: in one five
year follow up of a cohort of 123 CABG patients in England,
Skinner et al34 found that 84% had returned to work one year
following the operation. Half (49%) were still working after five
years. A larger percentage of sick-listed individuals among the
CABG patients aged <45 years were described by Noyez et al31 in
the Netherlands: 60% were working after one year.
Among patients following an uncomplicated PCI in Australia,
73% were already at work within six to eight weeks. The duration
of sick leave was 25 days.30 After one year, 79% of all patients
were still working.
Predictors
Two studies have shown similar findings. According to Lundbom
et al,27 higher age, long duration of the disease prior to the
intervention, previous MI and physically demanding work predict
lengthy sick leave. Patients who returned to work had a
significantly shorter waiting time and sick leave prior to surgery
than patients who were placed on disability pension. Caine et al18
showed that in waits exceeding six months, more than half of the
patients ended up outside of the labour market after PCI/CABG.
Boudrez et al16 showed that patients’ motivation to return to work
and the conviction that they are able to manage it had the greatest
impact on return to work. In this study, patients returned to work
on average after 15 weeks. From the other studies following CABG,
Bryant et al17 and Gehring et al21 showed that lower educational
level, female gender and poor self-confidence played a negative role.
After successful PCI, Fitzgerald et al20 showed that 59% had
returned to work after one month and 87% after one year. Even
here, the patient’s desire to return to the job was of major
importance. Despite a successful procedure and good physical
ability, the patients who remained on sick leave lacked self-
confidence about their possibility to return to work.
Differences between PCI and CABG
Two randomised, controlled trials (RITA33 and BARI35)
compared dilation to surgery in terms of the duration of sick
leave. In the BARI study from the US, Hlatky et al22 described an
82% return to work in both the PCI and the CABG groups,
although patients had a substantially shorter sick leave following
PCI (5 vs 11 weeks). After five year follow up, there were no
differences between the groups. Half of the individuals in the PCI
group had undergone a CABG.35
In the RITA study from England, Pocock et al33 reported similar
results despite certain differences in the inclusion criteria, compared
to the BARI study. There was no difference in the number of patients
that returned to work from five months up to three years following
intervention. Initially, there was a shorter sick leave period in the PCI
group: 25% vs 39% returned to work after one and two months,
respectively, compared with 9% after two months in the CABG group.
Four studies compared PCI and CABG, but without
randomisation. In the US, Holmes et al24 compared the outcome
following coronary angiography where treatment was PCI, CABG or
medication alone depending on the indications and coronary
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HeartWise Autumn 2004
Table 2. Studies included – PCI and CABG
Author and Aim Focus of study No. Mean age Type of sick leave data Intervention Return-to- Results
country distribution work (%)
Boulay,15 To compare a rehabilitation Men <60 years, working 121: 59 48.4 vs Via an examination one Combined rehabilitation 92 vs 89 No difference between the groups.
Canada programme vs standard before CABG vs 62 50.7 year after CABG programme vs standard Length of sick leave before CABG,
treatment after CABG, after care physical strain at work, other disease,
predictors for RTW education, angina and symptom
duration were predictive for RTW
Boudrez,16 To study RTW 1 year after Consecutive group patients 137 50±6 Via mailed survey/telephone: Opportunity to participate 80.8 Positive expectation about work,
Belgium CABG in relation to after CABG <60 years return-to-work 12 in rehabilitation physical strain, stress and other
psychological, social and months after CABG programme (48.5%) somatic symptoms were predictors
clinical variables
Bryant,17 Predictors for RTW after Consecutive group men 79 <65 years Via patient interview 3 CABG 57 37% RTW at 3 months, 57% at
England CABG after CABG <65 years and 12 months after at one year. Work before CABG
CABG and social class predictors
Caine,18 Predictors for RTW after Consecutive group patients 100 51±6 Via mailed survey/ CABG 73 Predictors: working before operation,
England CABG after CABG <60 years telephone: RTW 3 and length of waiting time and
12 months after CABG remaining physical limitations
Engblom,19 RCT of cardiac Consecutive group men 125: 66 52 vs Via patient interview 6 Combined rehab programme 56 vs 38 Patient views on work capacity,
Finland rehabilitation vs standard after CABG <65 years vs 59 51±6 and 12 months after (exercise, psychosocial functional class, desire to RTW and
treatment after CABG with CABG support) vs standard sick-leave duration before CABG
RTW as main parameter treatment were predictors
Fitzgerald,20 Predictors for early RTW Patient’s successful first-time 82 52±9 Questionnaire and patient PCI 87 At 1 month 59% RTW, 87% after
US after first time and PCI, working before interview at 1 and 6 6 months. Patients with high
successful PCI the intervention months after PCI self-efficacy RTW earlier
Gehring,21 Predictors for RTW Consecutive series of 249 53.4 Questionnaire 16 months CABG 44.3 37% (disability) pension and 17%
Germany after CABG patients after CABG, after angio and on sick-listed after 1 year. Predictors:
working before op average 1 year after symptom free and work capacity
CABG post-op, degree of revascularisation;
also work-related factors
Hlatky,22 RCT of PCI vs CABG in Patients who worked 409: 192 During 4 years, every third PCI vs CABG (part of 82 vs 82 PCI patients on average returned
US patients who had a job before PCI/CABG vs 217 month detailed info on BARI study) after 4.9 weeks vs CABG
before the intervention, type and level of work patients after 10.9 weeks
subgroup from BARI
Hofman- Cardiac rehabilitation at Patients from a consecutive 87: 46 53±7 Patient questionnaire Stay at rehabilitation centre 74 vs 78 After 2 years: 68 vs 61% RTW.
Bang,23 special rehab centre vs series successful PCI <65 vs 41 1 and 2 years after including long-term follow No significant differences in RTW
Sweden standard treatment years, working before the randomisation up vs standard treatment or quality of life
after PCI intervention
Holmes,24 RTW in 3 groups post- Patients after PCI: 1,150 53.7 Questionnaire on average CABG or conservative 70.4 vs In the group <60 years, 81-86%
US PCI: successful vs successful vs 18 months after PCI therapy if PCI unsuccessful. 65.4 vs 61.8 RTW. On successful PCI RTW
unsuccessful with later CABG unsuccessful + CABG No randomisation after average 7 days, after CABG
vs unsuccessful with vs unsuccessful + medical 73 days, after conservative
later conservative therapy therapy therapy 13 days
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HeartWise Autumn 2004
Table 2. Cont’d
Author and Aim Focus of study No. Mean age Type of sick leave data Intervention Return-to- Results
country distribution work (%)
Janzon,25 RCT of invasive vs non- Patient with unstable 933: 464 37–65 Loss of working days Early angiography vs n/a Sick leave on average 102
Sweden invasive treatment for coronary disease: vs 469 before RTW as part of standard conservative days for the invasive part vs 122
unstable coronary disease invasive vs non-invasive health economic analysis examination process for the conservative part
Laird- Comparison between non Men <60 years after 125 vs 94 51 vs Via mailed survey PCI or CABG depending on 96 vs 83 53/55 PCI patients RTW, 49/59 CABG
Meeter,26 the -randomised groups of PCI PCI or CABG 52±6 /telephone: return-to-work indication, non-randomised patients. Predictors: work ability
Netherlands and CABG patients as 1 year after PCI or CABG before PCI/CABG, age, remaining
regards RTW angina after operation
Lundbom,27 Predictors for RTW after All survivors CABG patients 196 57.8: Median follow up with Standard treatment 49 Sick leave duration and waiting
Norway CABG with job before CABG 36-69 questionnaire after 32 time before CABG affects RTW,
months (19-52) as does age, type of job, duration of
disease history and previous infarction
Mark,28 US Observation study of Consecutive group for 1,252: 312 54: 46-60 Via mail survey/telephone: 3 groups: PCI, CABG or 84 vs 79 No significant differences in 1 year follow
patients after coronary coronary angio, <65 PCI vs 449 RTW 12 months after conservative therapy vs 76 up. Subgroup analysis: RTW median
angio treated with PCI, years, with job before CABG vs angio 18 days after PCI, 54 days after CABG
CABG or medication alone the study 491 med and 14 days for medical treatment alone
McGee,29 Comparison between Consecutive group patients 119 PCI vs 53.9±7.3 Via mail survey/telephone: 2 groups: PCI or CABG, 68 vs 59 No significant differences but PCI
Ireland non-randomised groups after PCI vs CABG 112 CABG vs 55.9±5 RTW 6-18 months after op non-randomised yielded higher percent early RTW:
of PCI and CABG patients 8 weeks post-op: 39 vs 12%
regarding RTW
McKenna,30 Observation study of Consecutive group patients 209 56: 30-78 Home visit or mail survey PCI 79 119 working before. 73% back at work
Australia patients after PCI after uncomplicated PCI 6-8 weeks after PCI and in control 6-8 weeks, median time 25
1 year after PCI days. Median for return to normal
social life 14 days
Noyez,31 Long-term follow up of Consecutive group patients 167 41.7±3 Register, questionnaire and CABG 59.5 131 in normal job before,
the younger patients after after CABG, <45 years telephone, follow up only 78 of these RTW
Netherlands CABG to 10 years
Perk,32 Case-control study of Consecutive group patients 147: 49 57±7 vs Data via patient visits, Combined cardiac 59 vs 64 No difference between the groups.
Sweden cardiac rehabilitation after after CABG vs matched vs 98 57±7 records and surveys rehabilitation programme vs In both groups long wait for CABG
CABG control patients from region standard treatment and long sick leave before operation
Pocock,33 Compare RTW up to 3 Participants in RITA trial: 963: 483 <60 Patient interview and PCI vs CABG in cases where 48.2 vs No difference 3 years after operation.
England years after PCI or CABG sub-study of men <60 years PCI vs 480 questionnaire after 1, 6, anatomy was comparable 52.3 However, differences in early RTW:
in RCT PCI vs CABG CABG 12, 24, and 36 months for both interventions PCI: 25 vs 39% 1 vs 2 months post-op;
CABG only 9% 2 months post-op
No difference 5 months after operation
Skinner,34 5 year follow up of Consecutive series of 353 57.2±7.3 Patient visits after 3, 6, 12 CABG 84 123 working before: 36% RTW after
England consecutive patients after patients after CABG and 60 months 3 months, 84% after 1 year and
CABG 49% after 5 years
The BARI 5 year follow up of patients Patients included in BARI 801: 374 61.8 vs 61.1 Patient visits after 4–14 wk, PCI versus CABG 69 vs 72 At visit 4-14 weeks: 55% PCI RTW vs
Investigators,35 randomised to PCI or CABG study; only those working PCI vs 427 6 months, 12 months, 36% CABG. No differences at later
US before PCI/CABG CABG thereafter annually to 5 yrs measurement points
anatomy. No difference was found between these three alternatives;
62-70% were at work after 18 months. The short sick leave periods
were noteworthy; on average, 7 days after PCI, 73 days after CABG
and 13 days in the group receiving conservative treatment alone.
Mark et al28 found that in a group of 1,252 consecutive patients
aged <65 years, 76-84% had returned to work one year following the
intervention. Short sick leave periods were reported: 18 days
following PCI, 54 days following CABG and 14 days following
conservative treatment.
From Europe, Laird-Meeter et al26 described a high level of return
to work in the Netherlands among male PCI and CABG patients aged
<60 years: 96% vs 83% after one year.
In a cohort in Ireland, McGee et al29 found a 68% return to work
in the PCI group and 59% in the CABG group 6-18 months after the
intervention. More PCI patients were back at work early (after eight
weeks): 39% vs 12%.
Sick leave in Sweden is substantially longer. In the FRISC II study
by Janzon et al,25 the mean duration of sick leave for patients who
had been working before the intervention was 102 days post-PCI
and 122 days post-CABG.
Interventions
The effect of cardiac rehabilitation on return to gainful employment
varied. Boulay et al,15 in a study from Canada, found no difference
between cardiac rehabilitation involving physical exercise and
standard care: 92% vs 89% of males aged <60 years returned to
work. Perk et al,32 in a Swedish case-controlled study, reported on a
post-CABG population where the patients participated in a three
month training programme.
Despite differences in physical performance and fewer re-
admissions to hospital in the study group, no difference was found
in return to work one year after surgery. Engblom et al19 assessed a
similar programme in Finland: no significant differences for the
cohort as a whole (56% vs 38%), but a difference in the patients aged
<55 years, favouring those who participated in rehabilitation.
Recently, a randomised, controlled trial by Hofman-Bang et al23
investigated inpatient rehabilitation following PCI where 46 patients
were treated with a residential programme to change lifestyle. These
patients were compared with 41 control patients who were offered
standard care: despite positive effects on risk factors, there were no
differences in return to work (74% vs 78%).
These studies show that most of the patients can return to work
following coronary artery intervention. PCI enables shorter sick leave
periods than CABG. However, in the long term, there is no
difference. Among the predictors, the patients’ motivation was
shown to be the most important factor for return to work.
Discussion
The following methodological deficiencies were observed in studies
not judged to have sufficient quality. Most of the studies have
focused on return to work rather than on sickness absence. Study
designs have been directed primarily at describing a medical course,
not at studying sick leave. Study populations were often selected
based on age, gender and the type of hospital or rehabilitation
clinic. Follow up times often varied among individuals in the same
study. Drop-out was often substantial. Selection effects were seldom
reported. Studies excluded, for example, students or housewives, or
included only those who were full-time employees prior to onset.
Information about the duration and level of sick leave was lacking
as was, in most articles, a description of the interventions intended
to influence or shorten sick leave.
Have the advances in cardiology within prevention, diagnosis,
treatment and rehabilitation since 1975 led to any changes in sick
leave? This review has shown that return to work has remained
largely unchanged during the entire period. Generally, only one-third
to one-quarter of surviving patients who were employed prior to
onset could not return to work. It is not certain that patients would
remain at work in the long term as follow up was often short.
Most of the included studies originated in the 1980s and the
early 1990s. In recent years, the number of scientific studies in
this field appears to have declined. Has the higher age at the
onset of disease and the increasing number of elderly heart
patients contributed to this?
Several studies have focused on factors that can predict return to
work. Physical predictors include the size of infarction, the
prevalence of complications during the acute phase, angina pectoris
and heart failure following the care episode. Statistical analysis has
shown a moderate correlation between the severity of the disease and
return to work.
Psychosocial factors have played a major role, such as depression
during and after the hospital stay, poor self-confidence or a poor
perception of one’s performance capacity and a lack of desire to
return to work.
Demographic and social predictors include age, gender,
educational level and place of residence, as well as various work-
related factors. Some differences exist in the predictors for MI
patients and PCI/CABG patients. Some of the PCI/CABG patients do
not have an acute onset and, hence, are at risk for a longer waiting
time for angiography and subsequent interventions. The duration of
waiting time is shown to be of importance.
Sick-listing practices for heart patients vary considerably among
countries due to various factors, e.g. different designs for sickness
insurance, labour market conditions and sick-listing traditions
among physicians. In Sweden, sick leave of at least three months is
common after MI or CABG, and barely shorter following PCI.25 In
several European countries and the US, the median duration of sick
leave is 60 days following MI and CABG, while sickness absence after
PCI is several weeks at most. Is there a reasonable explanation for the
relatively lengthy sick leave in Sweden, for example waiting time
prior to PCI/CABG? Is there a need for more distinct European
guidelines for sick-listing of cardiac patients?
Conclusion
This review has shown that following CAD, the majority of patients
return to their previous jobs, although several leave the labour
market prematurely. Advances in emergency care have improved
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the medical prognosis, but the social prognosis, i.e. the opportunity
to return to work, appears to remain unchanged over the past
decades. Unfortunately, good quality studies are not available to
provide a basis for interventions that can reduce sickness absence.
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Joep Perk, DMSC, FESC, Associate Professor, Department of
Internal Medicine, Oskarshamn District Hospital, Oskarshamn,
Sweden. Email: joep@ltkalmar.se
