Swedish Council on Technology Assessment in Health Care (SBU). Chapter 8. Sick leave due to coronary artery disease or stroke

Abstract

The assessment of the literature on sick-leave with cardiovascular diseases include only studies with sufficient scientific quality. These studies describe sick leave following stroke, myocardial infarction, coronary artery bypass grafting (CABG), or percutaneous coronary intervention (PCI). We found limited scientific evidence for the following results: After stroke, more than half of the patients of working age returned to work (RTW) during the first year following onset (higher rate for the younger patients). The consequences of brain damage, e.g. impaired ADL ability or cognitive capacity, play an important role in this respect. Also after myocardial infarction most patients RTW. PCI is a milder coronary artery intervention than CABG and RTW is more rapid. However, 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 due to these conditions in Sweden is longer than in other countries although there is no scientific evidence to support this practice. It appears that the interest in research on sick leave in patients with cardiovascular diseases has waned in recent years. Developments in acute cardiological care should inspire renewed scientific involvement in this area of research.

Full text

ORIGINAL ARTICLE
Chapter 8. Sick leave due to coronary artery disease
or stroke
Joep Perk
1
and Kristina Alexanderson
2
1
Oskarshamn Hospital, Oskarshamn, Sweden,
2
Section of Personal Injury Prevention, Karolinska Institutet, Stockholm, Sweden
Scand J Public Health 2004; 32 (Suppl 63): 181–206
The assessment of the literature on sick-leave with cardiovascular diseases include only studies with sufficient scientific
quality. These studies describe sick leave following stroke, myocardial infarction, coronary artery bypass grafting (CABG),
or percutaneous coronary intervention (PCI). We found limited scientific evidence for the following results: After stroke,
more than half of the patients of working age returned to work (RTW) during the first year following onset (higher rate for
the younger patients). The consequences of brain damage, e.g. impaired ADL ability or cognitive capacity, play an
important role in this respect. Also after myocardial infarction most patients RTW. PCI is a milder coronary artery
intervention than CABG and RTW is more rapid. However, 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 due to these conditions in Sweden is longer than in other countries although there is no scientific
evidence to support this practice. It appears that the interest in research on sick leave in patients with cardiovascular diseases
has waned in recent years. Developments in acute cardiological care should inspire renewed scientific involvement in this
area of research.
Joep Perk, Oskarshamn Hospital, SE-572 28 Oskarshamn, Sweden. Tel: z46 491 782 000, fax: z46 491 782643.
E-mail: joep@ltkalmar.se
INTRODUCTION
Cardiovascular diseases, such as coronary artery
disease and stroke represent the third most common
cause for long-term sickness absence in Sweden. These
diagnoses accounted for 8% of the disability pensions
in 2001 and 6% of sickness absence (RFV, Statistical
Information, 2003:1). There are no clear guidelines as
regards the optimal duration and degree of sick leave
with these conditions. Likewise, there are no well-
defined measures to promote RTW or prevent
disability pension. The initiative for and design of
rehabilitation programmes remain with the individual
physician. In practice, this can mean broad variations
in the type and level of measures taken.
This chapter reviews the current knowledge for the
purpose of providing supportive information to those
aiding the patient’s RTW following stroke, myocar-
dial infarction, or coronary artery surgery.
The search for studies was based on the same
literature databases and the same search terms as used
in the project generally, reference lists of reviewed
publications, and via contacts with other researchers
(see Chapter 2). Approximately 460 publications
addressing sickness absence due to cardiovascular
diseases were identified. In assessing the relevance of
these studies, only two diagnostic areas, i.e. stroke and
coronary artery disease, were included.
The stroke group covers cerebrovascular diseases
(numbers in parentheses reflect the ICD-10 classifica-
tion, WHO): Subarachnoid haemorrhage (I60), cere-
bral haemorrhage (I61), cerebral infarction (I63). The
group of coronary artery diseases covers anginal chest
pain (I20), myocardial infarction (I21 and I22),
chronic ischaemic heart disease (I25), heart failure
(I 50), and conditions following various types of
coronary artery interventions. Heart transplantation
was not included. In addition to these areas, we
found most studies in the diagnostic area of high
blood pressure. Here, the quality of the studies was
consistently low. The studies mainly addressed a
presumed correlation between sickness absence and
being aware of having high blood pressure. Other
cardiovascular diseases, i.e. the other groups in
ICD10 ‘‘I10 – I99’’, have been excluded since none,
or very few, studies could be identified within the
respective diagnostic areas.
For stroke, studies of data obtained before 1965
were excluded, for coronary artery disease, that date
was set at 1975 as the advancements in diagnostics
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and treatment since 1975 rendered earlier studies less
relevant for current practice.
Most of the studies on sickness absence after stroke
and coronary artery disease have focused on RTW
rather than on sickness absence. The term RTW
implies that only those who were working prior to
stroke or myocardial infarction are addressed. We
have not included studies where it was not possible to
differentiate sickness absence/disability pension from
other types of causes for not being at work. Likewise,
we did not include studies where it was not possible to
distinguish the data on individuals who had been
working prior to stroke versus those who had not.
The following text presents only the results for
working people, even when the tables show that
elderly persons are included in the studies.
SICK LEAVE AND STROKE
Stroke is one of the major diseases in Sweden,
affecting approximately 25,000 people annually.
Stroke is a collective name covering cerebral infarc-
tion (approximately 85%), intracerebral haemorrhage
(approximately 10%), and subarachnoid haemorrhage
(approximately 5%). Over 80% of those affected by
stroke are older than 65 years of age (1). Acute disease
affecting the blood supply to the brain can lead to
substantial disability at all ages and long-term sick
leave when it affects individuals of working age. The
incidence of stroke among people v65 years of age is
50 per 100,000 population.
In reviewing the studies, and when possible,
haemorrhages were differentiated, mainly as subara-
chnoid haemorrhages (SAH, group A) and cerebral
infarction (ischaemic stroke, group B). In studies with
mixed data (SAH and ischaemic stroke) the data
from the different diagnostic groups were analysed
separately.
ASSESSING RELEVANCE AND QUALITY
Of the 64 publications identified on sickness absence
following stroke, 34 were found to be relevant, i.e.
presented data on sick leave and/or return to work.
Sickness absence was seldom discussed or defined;
rather the concept ‘‘return to work’’ was used. No
randomised controlled trials on the effects on treat-
ment or other interventions for RTW were identified.
In a review of quality based on the criteria
presented in Chapter 2, nine of these studies (2 – 10)
were found to be of low quality (Table 8.I) and one
study was of medium quality (11), while the quality of
the remaining 23 studies was insufficient in relation to
the aim of this literature review.
RESULTS
GROUP A: SUBARACHNOID AND
INTRACEREBRAL HAEMORRHAGES
(TABLE 8.I)
Four studies have been identified, all prospective
cohort studies whereof one was of medium and three
were of low quality (2, 3, 7, 11). The patients (total
753) in the studies received either conservative therapy
or surgery, or both. The average follow-up period
varied from 6 to 66 months. The mean age in most of
the studies was approximately 50 years. In the group
of surviving patients with SAH, where no considera-
tion had been taken to functional level on discharge,
generally two of three patients returned to work
during the first year after onset (the higher the rate the
younger the patients) (2, 7, 11). A 38% RTW after
three months was reported (2). Cognitive disorders
were observed in all studies, and represented an
obstacle for RTW.
A detailed analysis of factors that influence sick
leave were reported among middle-aged patients
(40 – 49 years) in Japan (11). In this study of
medium quality it was found that 77% of the men
and 62% of the women had RTW one year after the
subarachnoid haemorrhage. Eighty percent of the
engineers and those working in agriculture and fishing
returned to work, but only 20% of the individuals in
transportation and communication. A lower ADL
(activities of daily living) status on discharge usually
contributed to long-term sick leave. Cognitive dis-
orders correlated with not returning to work.
In studies that included SAH (6, 8, 10), e.g. stroke,
the results point in the same direction as in these four
studies. Location of the haemorrhage influenced the
prognosis: individuals with a ruptured vessel in the
brain stem had the longest sick leave.
Evidence
The assessment of evidence is based on one study of
medium quality and three studies of low quality. Most
individuals of working age that survive an SAH
returned to work within one year. However, there are
too few studies to scientifically support the evidence.
GROUP B: ISCHAEMIC STROKE (TABLE 8.I)
Six studies were found to have sufficient but low
quality (4 – 6, 8 – 10). Most were prospective cohort
studies, and in total 917 patients were included.
Patients in these studies were treated with conservative
therapy since surgery was not appropriate in these
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groups. Follow-up time varied from 12 to 212 months
following onset.
The studies with the longest follow-up included 74
Swedish patients v40 years of age where 73% of the
group had RTW after 51 months, on average (4). The
study is based on patients from the 1960s and 1970s.
Similar and comparable results, but with shorter
follow-up (averaging 32 months), have been described
by Neau et al. (9) among younger French patients
from the 1990s: 71% returned to work. The patients
were sick listed for 8 months on average. One fourth
required adaptation of the job. Depressive symptoms
were frequent.
Saeki et al. (10) found that 58% of stroke patients in
Japan could RTW, but that the patients with physical
jobs or with remaining paresis had difficulties in
returning to work. Kotila et al. (6) confirmed that
remaining neurological deficit (loss of intelligence
and memory) and social factors (living alone) were
relevant predictors for not returning to work. In the
USA, Howard et al. (5) found that 28% of stroke
patients under the age of 65 years had returned to
work and 9% over the age of 65 years, in a 12-month
follow-up. A logistic regression analysis of data
showed that low age, good functional ability before
hospital discharge, office work and stroke in the right
cerebral hemisphere was associated with a higher
chance for returning to work.
The literature review showed that more than half
of the individuals below retirement age who had
survived an ischaemic stroke, returned to work within
the first year following onset. One study showed
that one in four patients required adaptation of the
job (9). Predictors for not returning to work include
high age, female gender, stroke in the left cerebral
hemisphere, greater level of hemiplegia, lower func-
tional level (ADL) and impaired cognitive capacity.
Other such factors include low educational level and
limited possibilities for adapting the workplace (10).
Depression is common (9). Only a few studies (5, 6, 8, 10)
included stroke patients in the 45– 65 year age group
despite that this group has the most stroke patients of
working age. The prognosis regarding RTW appears to
be less favourable in the higher age groups.
Evidence
There is limited scientific evidence that more than half
of those of working age return to work following
ischaemic stroke (Evidence Grade 3).
DISCUSSION
Many of the publications were identified through
reference lists in other articles rather than from
searching the literature databases. ‘‘Return to work’’
rather than sickness absence was the search term
yielding the greatest number of ‘‘hits’’. Here, this
diagnostic area differs substantially from the other
two that are addressed in this report, i.e. musculo-
skeletal and psychiatric disorders. The point of departure
is somewhat different in this diagnostic group: all
diagnosed stroke patients have been sick listed if they
were eligible for sickness benefit insurance. This means
that it is not productive to study causal factors for this
type of sick leave since they would probably be the
same as the causal factors for the stroke itself, and
impossible to differentiate from these. This is
probably the reason why the focus has been on
return to work. Other outcome measures might have
been the percentage receiving full or partial disability
pension or those on long-term sick leave.
In several studies, return to work has not been the
focus of the study, only a peripheral finding. This is
problematic because of the potentially strong pub-
lication bias associated with the secondary findings
one chooses to include. Despite the limited scientific
quality and the methodological difficulties in compar-
ing patient groups there appears to be, somewhat
unexpectedly, a brighter outlook in the prognosis for
the younger patients: two of three return to work,
usually within the first six months following stroke.
Only one in four patients required adaptation of the
workplace, and more than half remained gainfully
employed in the long term. The outcome appears to
be substantially better than the common perception
in health care, probably since the clinical impression
of stroke is associated with more disabled elderly
patients.
There is a tendency for differences in the results
between studies from Europe and the USA (one
study): the percentage that returns to work is lower in
the USA. The differences in rehabilitation, interven-
tions at the workplace, attitudes, employment rates,
insurance systems, and labour markets may be
possible explanations.
The outlook becomes darker on closer analysis:
many patients report a worse, or even poor, quality of
life where hidden disability plays a key role: impaired
cognitive ability, remaining neurological loss. Many
patients experience depression and marital stress that
can lead to divorce. One’s circle of friends becomes
smaller and patients become increasingly isolated
socially.
The studies are of a very general character. More
information is needed for the results to be applicable.
For example, there are four subgroups of thrombo-
embolic stroke disorders, based on the vascular
territory affected, and to what degree. Information
on how sick leave varies by type of stroke would be
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valuable. Most of the studies are descriptive at a
general level, and are more likely to inspire further
research within the field than to provide a basis for
clinical interventions.
Numerous hospitals and some rehabilitation centres
in Sweden provide rehabilitation following stroke.
Their aim is to help patients return to an independent
and worthwhile life without being dependent on the
health services or others. There are many individual
examples of good results from interventions aimed at
occupational rehabilitation. However, there are no
well-executed studies that assess different methods
for limiting sick leave and helping patients to
both return to, and remain in, gainful employment.
These studies should include non-selected consecutive
patient groups where interventions are assessed via a
randomised design.
CONCLUSIONS
The degree of disability for people of working age
affected by stroke varies from nearly symptom-free to
living at a nursing home. There is no scientific
evidence on patient-adapted methods for influencing
return to work in relation to the degree of the residual
function impairment.
Few studies are available on post-stroke sickness
absence and return to work, and most are purely
descriptive. These studies provide limited scientific
evidence that more than half of working-age patients
return to work following ischaemic stroke.
SICK LEAVE AND CORONARY ARTERY
DISEASE
Coronary artery disease is the most common cause of
death in Sweden in both women and men. Since the
1960s, there has been a significant improvement in
diagnostics and treatment, both with coronary artery
surgery and pharmaceuticals.
Coronary artery bypass grafting (CABG) has
become established as a treatment method, and is
even used in elderly patients, but the number of
operations has been limited in recent years since more
patients can be treated with percutaneous coronary
intervention (PCI). New PCI methods involving
implantation of stents (a net shaped tube that prevents
collapse of a dilated artery) have improved the
medical outcomes.
Pharmacotherapy has also provided new opportu-
nities, where the introduction of agents to dissolve
blood clots (fibrinolysis) in the 1980s represented the
starting point for successful acute coronary care.
Currently, a considerable percentage of myocardial
infarction patients in Sweden receive fibrinolysis even
prior to arrival at hospital.
Knowledge about the importance of risk factors
such as smoking, hypertension, blood lipid disorders,
and insufficient physical activity has created growing
involvement in preventive cardiac care before and
after manifestation of the disease. Most coronary
patients are treated with several pharmaceuticals
concurrently, e.g. acetylsalicylic acid, beta-blockers,
statins, and ACE inhibitors. Most hospitals in Sweden
have a well-developed post-cardiac care programme
where various interventions to achieve a healthy
cardiovascular lifestyle are combined: physical fitness,
information to patients and relatives, dietary advice,
smoking cessation, and special courses to control
stress. Specially trained nurses (coronary care nurses)
co-ordinate these interventions.
Developments in prevention and treatment have
contributed to a marked reduction in premature
death, to fewer patients of working age with heart-
failure-related functional impairments and to the
onset of disease at increasingly higher ages. How
has this trend influenced sickness absence and sickness
certification in Sweden?
ASSESSING RELEVANCE AND QUALITY
In reviewing approximately 460 publications, 104 were
found to be relevant, all of which are presented in the
lists of references. In an assessment of quality, three
studies were found to be of medium quality (12 – 14)
and 32 studies were found to be of low quality with
regard to the aim of the review. These studies are
presented here in two groups, i.e. those concerning
patients following myocardial infarction and those
concerning patients who have undergone a coronary
artery procedure (PCI, CABG). Most of the studies
used a prospective cohort design, but there are also
several randomised controlled trials and case-control
studies.
RESULTS
SICK LEAVE IN MYOCARDIAL INFARCTION
PATIENTS (TABLE 8.II)
Fourteen studies were found to be of sufficient
quality, all of which focus on RTW among sick-
listed persons. The studies can be divided into three
groups: descriptive, analytical, and intervention stu-
dies. Two studies (15, 16) describe outcomes during
the first year following infarction, six studies (17 – 22)
present predictors for return to work, six studies
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(23 – 28) describe the outcome of interventions aimed
at limiting sickness absence.
Outcome following myocardial infarction
Herlitz et al. (16) in a prospective cohort study
investigated all patients below 65 years of age with
myocardial infarction and receiving care at Sahlgrenska
Hospital in Gothenburg, Sweden, and who were
employed part-time or full-time prior to infarction.
They found that 37% had returned to full-time work
and 12% to part-time work one year following
myocardial infarction. Higher age and larger infarc-
tions influenced the outcome negatively.
Boudrez et al. (15), in the city of Gent, Belgium,
found that of all men below 60 years of age who had
experienced myocardial infarction only a few were on
long-term sick leave due to heart disease. During the
first year, 85% had RTW.
Predictors for RTW
Maeland et al. (17, 18) followed 249 consecutive
myocardial infarction patients aged v67 years for one
half year following onset: 25% were still on sick leave.
They found that the following social and psycholo-
gical factors negatively influenced the possibility of
RTW: 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 al. (22) in a cohort study of
201 male myocardial infarction patients v60 years of
age who were employed prior to their infarction,
showed that the patients’ motivation to RTW was the
most important predictive factor. No differences were
found between age groups, but patients with physi-
cally 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. The
studies were performed before the availability of
fibrinolysing substances.
From the time since this treatment was introduced,
similar findings have been reported regarding the
duration and predictors of sick leave: a study of first-
time infarction patients from New Zealand found that
58% of the patients v65 years of age were working
after half a year (19). The patients’ perception that the
disease was an obstacle for RTW predicted longer sick
leave. Soejima et al. (21) showed that 83% of male
Japanese myocardial infarction patients v65 years of
age were back at work after eight months. The
prevalence of depression during the care period, and
worry concerning one’s own health predicted lower
RTW. Smith et al. (20) found in a study from USA
that individuals with higher socio-economic status had
a greater chance of RTW. In the study, 72% of all
patients v70 years of age returned to work, a higher
number in those with high socio-economic status.
Interventions
By using various forms of counselling and support
following infarction, is it possible to reduce the
duration of sick leave and the percentage who do
not return to work? In a randomised controlled trial,
Dennis et al. (25) studied whether advice on sick leave
from a heart specialist at a university hospital to the
patient’s family physician would help shorten sickness
absence. The group receiving advice reported an
average sick leave spell of 51 days versus 75 days in
the control group, representing an economic gain of
2 102 USD per patient. When the same trial was
repeated by a non-hospital-based cardiologist, the
results could not be reproduced, probably because of
the selected low risk population; most returned to
work within a short period (28).
Studies of different types of combined cardiac
rehabilitation programmes have been published
having the following in common: patient and family
information, physical exercise, smoking cessation and
regular contact with a coronary nurse. Bengtsson (23),
in a randomised trial from Gothenburg, could 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, Hedba¨ck et al. (27) did not find any effect
from the programme after the first year in comparison
with a consecutive study group and a control group
(62% versus 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 al. (26) offered three different alter-
natives for aftercare: participation in an exercise
group, exercise including counselling or only standard
aftercare. In this study from the USA only a few were
sick listed, 94% returned to work already after six
months regardless of the design of aftercare.
This literature review has shown that at least
half of the patients following myocardial infarction
can return to work. Several studies showed that
the duration of sick leave is influenced mainly by
psychological and social factors such as depression,
self-confidence, low educational level, physically
demanding work, or low work satisfaction. The
outcomes of intervention such as different aftercare
programmes and counselling are uncertain regarding
RTW.
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Evidence
There is limited scientific evidence that the majority of
patients who survived a myocardial infarction
returned to work within the first year following the
infarction (Evidence Grade 3).
SICK LEAVE IN PATIENTS FOLLOWING PCI
OR CABG (TABLE 8.III)
Twenty-one relevant studies were identified in the area
of sick leave/return to work in patients after these two
types of coronary artery interventions. As with
myocardial infarction studies, there are three main
groups: descriptive, predictive, and interventional
regarding both type of coronary artery intervention
and aftercare. In three studies (13, 29, 30) the outcome
is described during the first year following the
intervention, and six studies (24, 31 – 35) investigated
the predictors for RTW following the intervention.
Seven studies (12, 14, 36 – 40) compared the results
between patients after PCI or CABG, and four studies
(41 – 44) described the outcome of rehabilitation
programmes. One study compared different strategies
for an acute coronary syndrome (45).
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 al. (30) found that
84% had returned to work after 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 v45 years were
described by Noyez et al. (29) in the Netherlands: 60%
were working after one year. No specific measures
were taken to influence RTW.
Coronary artery dilation; among patients following
an uncomplicated PCI in Australia, 73% were already
at work within 6 – 8 weeks. The median time of sick
leave was 25 days (13). After one year, 79% of all
patients were still working.
Predictors
What factors predict the duration of sick leave after
PCI and CABG? Two studies have shown similar
findings: according to Lundbom et al. (35) higher age,
long duration of the disease prior to the intervention,
previous myocardial infarction, and physically
demanding work predict lengthy sick leave following
the intervention. Patients who RTW had a signifi-
cantly shorter waiting time and sick leave prior to
surgery than patients who were granted disability
pension, even though this could not be explained by a
selection effect, i.e. that patients more inclined to
work did not receive priority on the waiting list. Caine
et al. (46) 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 al. (31) showed that patients’ motivation
to RTW and the conviction that they were able to
manage it had the greatest impact on RTW. In
this study, patients returned to work on average after
15 weeks.
From the other studies following CABG, Bryant
et al. (32) and Gehring et al. (34) showed that
lower educational level, female gender, and poor self-
confidence played a negative role.
After successful PCI, Fitzgerald et al. (33) showed
that 59% of 82 patients had RTW already 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 stayed sickness absent
lacked self-confidence about their possibility to RTW.
Differences between PCI and CABG
Two randomised controlled trials (RITA (14) and
BARI (12), attempted to answer the question of
whether dilation was preferable to surgery in terms of
the duration of sick leave. In the BARI study from the
USA, Hlatky et al. (36) described an 82% RTW in
both the PCI and CABG groups, although patients
had a substantially shorter sick leave following PCI
(five versus eleven weeks). After five-year follow-up,
there were no differences between the groups. Half of
the individuals in the PCI group had then undergone
a CABG (12).
In the RITA study from England, Pocock et al. (14)
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, the sick-leave spell in
the PCI group was shorter: 25% versus 39% RTW
after one and two months respectively, versus 9% after
two months in the CABG group.
In addition to these two randomised trials, four
studies compared PCI and CABG, but without
randomisation, in the USA Holmes et al. (37)
compared the outcome following coronary angiogra-
phy where treatment was PCI, CABG, or medication
alone depending on the indications and coronary
anatomy. No difference was found between these
three alternatives; 62 – 70% were at work after
18 months. From a Swedish perspective, the short
sick-leave spells were noteworthy; on average seven
sick-leave days following successful PCI, 73 days
following CABG and 13 days in the group receiving
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conservative treatment alone. In Sweden patients
usually are sickness certified for much longer periods.
In a similar study from the USA, Mark et al. (39)
found that in a group of 1 252 consecutive patients
aged v65 years, 76 – 84% had RTW in one year.
Short sick-leave spells were reported: 18 days follow-
ing PCI, 54 days following CABG and 14 days
following conservative treatment.
From Europe, Laird-Meeter et al. (38) described a
high rate of RTW in the Netherlands among male
PCI and CABG patients aged v60 years: 96% versus
83% after one year.
In a cohort of consecutive patients in Ireland,
McGee et al. (40) found a 68% RTW 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% versus 12%. None of the
four studies reported any special interventions,
beyond PCI/CABG, to influence the duration of
sick leave. Sick leave in Sweden is probably substan-
tially longer than in the studies presented above, but
actual diagnosis-specific data is lacking. In the FRISC
II study, Janzon et al. (45) investigated the outcome of
early invasive versus conservative strategies for
unstable coronary disease. A majority of the patients
received PCI or CABG. Here, the mean duration of
sick leave for patients who had been working before
the intervention was 102 and 122 days, respectively.
Interventions
Cardiac rehabilitation, especially physical exercise,
helped patients regain good physical work capacity in
cardiac stress testing (treadmill, bicycle) following
CABG and a better quality of life. However, the
effects on return to gainful employment varied.
Boulay et al. (41), in a study from Canada, found
no difference between cardiac rehabilitation involving
physical exercise and standard care: 92% versus 89%
of males aged v60 years returned to work. Perk et al.
(44), in a Swedish case-control study, reported on a
consecutive post-CABG population where the patients
participated in a three-month training programme at
the sub-maximal load level, combined with a home
exercise programme. Despite differences in physical
performance and fewer re-admissions to hospital in
the study group, no difference was found in RTW one
year after surgery. Engblom et al. (42) assessed a
similar programme in Finland in a randomised
controlled trial: he found no significant differences
for the cohort as a whole (56% versus 38%), but a
difference in the patients v55 years of age, favouring
those who participated in rehabilitation.
Recently, a randomised controlled trial by Hofman-
Bang et al. (43) investigated rehabilitation at a special
institution following PCI where 46 patients were
treated with an intensive residential programme to
change their 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% versus 78%).
All studies show that most of the patients can RTW
following coronary artery intervention. The two
randomised controlled trials and four other compara-
tive studies found that PCI, in the short term, led
to substantially shorter sick-leave spells than CABG.
However, in the long term, there is no difference between
these treatment alternatives. Among the predictors,
based on multivariate analysis, the patients’ motivation
was shown to be the most important factor for RTW.
No studies of cardiac rehabilitation programmes have
shown effects on the duration of sick leave.
Evidence
There is limited scientific evidence that most patients
return to work after PCI or CABG and shorter sick-
leave spell directly after PCI than after CABG, but
similar in the long term (Evidence Grade 3).
DISCUSSION
General
The following methodological deficiencies were found
in studies considered not to have sufficient quality,
regarding stroke or coronary artery disease.
Study designs have been directed primarily at
describing a medical course, not at studying the
type and duration of sick leave. Study populations
were often selected based on age, gender, ADL ability
at discharge (stroke), and the type of hospital or
rehabilitation clinic. Follow-up times often varied
among individuals in the same study. In most studies,
RTW was only a peripheral outcome, not the
main focus of the study. Hence, the data collection
methods, definitions of measures, and analytical
methods as regards sickness absence and RTW were
generally deficient. Particularly in studies where data
were collected by questionnaires, the outcomes were
seldom adequate since, among different patients in the
same study, the time between onset and responding to
the questionnaire could vary from days to several
years.
Dropout was often substantial and not fully
reported. Primary dropout was seldom reported and
secondary dropout was described in general terms
without details. Selection effects and their potential
impact on bias were seldom reported. Some studies
excluded, e.g. students or housewives, and other
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studies 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
sick leave. In those not working, it was often unclear
if they were sick listed, unemployed, old age pensioners,
or housewives. Differences in sickness insurance,
pension benefits, etc made it difficult to compare
studies. The correlation between the degree of
disability and sickness absence was seldom analysed.
Precision in the studies varied.
Heart disease, both medical, and social advances?
In the introduction, we asked if the advances in
cardiology regarding prevention, diagnosis, treatment,
and rehabilitation since 1975 have led to changes in
sick leave due to heart disease. The literature review
has shown that RTW has remained largely unchanged
during the entire period. Generally, only one third to
one fourth of surviving patients who were employed
prior to onset did not RTW following myocardial
infarction, PCI, or CABG. However, it is not certain
that the patients would have been able to remain at
work in the long term since follow-up periods were
often relatively short.
Advances in emergency care have improved the
medical prognosis, but the social prognosis, i.e. the
opportunity to RTW, appears to be unchanged.
Furthermore, this has barely been studied in recent
years. PCI has probably contributed toward quicker
RTW, but in longer follow-up it has shown the same
levels of sickness absence as coronary artery surgery.
Most of the included studies originated from the
1980s and the early 1990s. In recent years, the number
of scientific studies in this field appears to have
declined even though this disorder accounts for a
substantial part of sickness absence and disability
pension in Sweden and other Western countries. There
may be several reasons for this. Our search strategies
may have been insufficient, or this type has not been
accepted by scientific journals. Has the higher age at
the onset of disease and the increasing number of
elderly heart patients contributed to this?
Predictors for return to work
Several studies have focused on the importance of
factors that can predict return to work. Physical
predictors include the size of infarction, the prevalence
of complications during the care episode, angina
pectoris and heart failure following the care episode.
Statistical analysis has shown a moderate correlation
between different measures for the degree of severity
of the disease and RTW. Psychosocial factors
have played a major role, such as the prevalence of
depression during and after the episode of care, poor
self-confidence, or a poor perception of one’s own
performance capacity and a lack of desire to RTW.
Demographic and social predictors include age,
gender, educational level, place of residence, as well as
various work-related factors. There are too few
studies on each factor to provide a foundation for
grading the evidence.
Some differences exist in the predictors for myocardial
infarction patients and PCI/CABG patients. Most of
the myocardial infarction patients are not on sick
leave prior to the acute onset of the disease. Some of
the PCI/CABG patients do not have an acute onset, and
hence are at risk fora longer waiting timefor angiography
and subsequent interventions. The duration of waiting
time is shown to be of importance for RTW.
Sick-leave duration: practice and possibilities for
change
Sick-listing practices for heart patients vary consider-
ably among countries. This may be due to various
factors, e.g. different sickness insurance systems,
labour market conditions, and sick listing traditions
among physicians. In Sweden, it appears that
physicians routinely sicklist heart patients longer
than physicians in other countries do. A sick leave
of at least three months is common after myocardial
infarction or CABG, and barely shorter following PCI
(45). In several European countries and the USA the
median duration of sick leave is 60 days (47) following
myocardial infarction and CABG, while sickness
absence after PCI is a few weeks at most. Is there a
reasonable explanation for the relatively lengthy sick
leave in Sweden, e.g. waiting time prior to PCI/
CABG? Are there obstacles that would prevent
Sweden from following the practice in other European
countries? Is there a need for more distinct guidelines for
sick listing of heart patients? According to a report from
the National Board of Health and Welfare (48) there are
wide regional variations in how longpeople are sicklisted
following a myocardial infarction, differences that
cannot be explained by differences in morbidity.
CONCLUSION
Following coronary artery disease, a majority of the
patients had RTW, although several leave the labour
market prematurely. Studies are not available to
provide a basis for interventions that can promote
RTW. Furthermore, the literature search provided no
evidence to support the relatively long (from an
international perspective) sick leave that is standard
practice for coronary heart disease in Sweden.
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Table 8.I. Studies included – stroke
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of
sick-leave data Intervention
% return-
to-work
(RTW) Results Quality
Findlay 1998
(2) Canada
Follow-up
of SAH
patients
regarding
mortality,
morbidity,
and disability
Prospective
cohort study
1994 – 1995
All patients
with SAH
receiving
care at a
regional
hospital
95 58 (23 – 74) Work status
after 1 year,
data on
sick leave by
questionnaire/
telephone survey
Standard treatment,
surgical and/or
medical
64 38% of all survivors
RTW after 3 mo,
64% after 1 year
Low
Helweg-Larsen
1984 (3)
Denmark
To study
the prognosis
after
spontaneous
intracerebral
haematomas
Prospective
cohort study
1974 – 1982
Patients
treated
conservatively
for intracerebral
haematomas
53 54 (10 – 79) Follow-up after
4.5 years
(average),
remaining
disability
and RTW
Conservative
medical therapy,
no surgical
intervention
38 8 fully fit for work,
others sick listed or
on disability pension
Low
Hindfelt 1977
(4) Sweden
Follow-up
of younger
stroke patients
regarding
mortality,
morbidity,
and disability
Prospective
cohort study
1965 – 1975
Stroke,
ischaemic
60 16 – 40 Follow-up after
average 51 mo
(3 d – 138 mo),
RTW among
survivors
at follow-up
Standard medical
treatment
85 35 full-time
employees after
average 5 months,
9 part-time employees.
None of the 44
dependent on
assistance
Low
Howard 1985
(5) USA
Factors
influencing
RTW
Prospective
cohort study
1968 – 1973
Stroke,
ischaemic
379 Data
missing
Data on 1-year
survivors.
Information on
type of work,
location of
stroke, etc
Standard medical
treatment
19 19% RTW after 3, 6,
and 12 mo. Age, race,
previous job, and
hemisphere determines
outcome (left side
worst)
Low
Sick leave due to coronary artery disease or stroke 189
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Table 8.I. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of
sick-leave data Intervention
% return-
to-work
(RTW) Results Quality
Kotila 1984
(6) Finland
To study
factors
influencing
recovery/sick
leave after
stroke
Prospective
cohort study
1978 – 1980
Stroke all: incl
SAH, only
1-year
survivors
154 61 (17 – 90) Follow-up income
data, 3 and 12
months: study
of neurology z
psychology
Standard medical
treatment
31 31% RTW at 3 mo,
55% at 1 year. Better
prognosis in younger
patients. Remaining
neurol deficit and
social factors
determine the
prognosis
Low
Lindberg
1992 (7)
Sweden
Follow-up of
disability
and RTW in
long-term
survivors
after SAH
Prospective
cohort study
1969 – 1980
Consecutive
survivors
after SAH
at a regional
hospital
324 50¡13 Follow-up after
average 5 years,
residual disability
and RTW
Standard
treatment,
surgical and/or
medical
57 Residual disability
usual despite
normal motor and
language function
Low
MacKay 1979
(8) England
Consequences
for the family
and society
of stroke
in younger and
middle-aged
patients
Prospective
cohort study
1977
All stroke,
mixed material
90 v65 Follow-up by
visit or
telephone.
Economic
data included
Standard
treatment,
surgical and/or
medical
38 38% had RTW. Stroke
involves major costs
for society and major
burden on family
Low
Neau 1998
(9) France
To study
RTW,
depression
and quality
of life after
stroke
in patients
aged 15 – 45
years
Prospective
cohort study
1990 – 94
Stroke,
ischaemic
71 15 – 45 Follow-up after
average 32
months,
remaining
disability
and RTW
Standard medical
treatment
71 73% back at work,
but 26% with job
adaptation. Return-to-
work after 8 mo on
average. 30% reported
poor Quality of Life.
Depression in 48%
Low
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Table 8.I. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of
sick-leave data Intervention
% return-
to-work
(RTW) Results Quality
Nishino 1999
(11) Japan
RTW after
SAH for
middle-aged
Japanese
Prospective
cohort study
1984 – 96
Consecutive
survivors
after SAH at
a regional
hospital
281 40 – 49 Standardised
1-year control,
data on sick
leave via
questionnaire/
telephone survey
Standard surgical
or medical
treatment
of SAH
76%
men
62%
women
76% of men, 62%
women RTW.
Higher % in those
with higher
education or
in agriculture
Medium
Saeki 1993
(10) Japan
RTW after
all types
of stroke, in
Japanese
under 65 y
Retrospective
cohort study
1986 – 90
Fit for work,
mixed stroke
material
244 v65
(18 – 64)
Follow-up after
1 – 6 y, RTW
Standard
treatment,
surgical and/or
medical
58 58% RTW (59%
women, 57% men),
fewer among
physical work,
apraxia or
muscle weakness
Low
Sick leave due to coronary artery disease or stroke 191
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Table 8.II. Studies included – myocardial infarction
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
% return-
to-work
(RTW) Results Quality
Bengtsson,
1983 (23)
Sweden
To study the
outcome of a
rehabilitation
programme
after myocardial
infarction
RCT
1973 – 1975
Infarction
patients
v65 y
87: 44
vs 43
39 – 65 Number of
sick-leave
days year 1,
% RTW
Combined
cardiac rehab
programme
85% No significant
difference in
RTW between
rehab and control
groups. On average
177 vs 172 full-time
sick-leave days, 58 vs
98 part-time days
Low
Boudrez
1994
(15) Belgium
RTW after
myocardial
infarction
in men
Retrospective
cohort study
1983 – 1988
All men
¡60 y in
a regional
infarction
register
295 m: 57.5 y Data via
mailed
survey 1991.
Only RTW
60%
participated
in a rehab
programme
85% 69% of all subjects
RTW, 85% of those
who worked before
MI. Few cases of
remaining sick leave
Low
Burgess
1987
(24) USA
RCT of
psychosocial
rehabilitation
after myocardial
infarction
RCT
1981 – 1984
Infarction
patients
who worked
at least
20 h/wk before
infarction
180: 89
vs 91
50.9¡7.4 Number RTW
3 – 4 and 13
months after
MI. Percent
moved to
another job
and sick listed
Nursing-based
psychosocial
intervention
88 vs
88%
10% still sick listed
after 13 months,
no effect from
intervention
Low
Dennis
1988 (25)
USA
RCT of targeted
advice based
on cardiac
stress test in
men after
uncomplicated
myocardial
infarction
RCT
1983 – 1985
Infarction
patients (men)
¡60, with
uncomplicated
MI, worked
before
201: 102
vs 99
49 and
50¡7
Detailed info
on time,
degree and
type of RTW
6 months
after MI.
Economic
consequences
Early stress
test and
targeted
advice on
sick-leave
duration to
primary care
91 vs
88 %
Shorter sick leave
with targeted advice
to primary care: 51
vs 75 sick-leave days
after MI. RTW:
32% reduction
which gave 2 102
USD as extra income
in the
study group
Low
Froelicher
1994 (26)
USA
To compare
two different
interventions
after myocardial
infarction with
standard
treatment
Prospective
rand. trial
1977 – 1979
All survivors
¡70 y with
myocardial
infarction
258: 84
vs 88
vs 86
57.1 vs
55.6 vs
56.3
RTW 12 vs
24 wk after
discharge
Physical
exercise,
vs physical
exercise z
education vs
standard
treatment
94% 83% returned to
work at 12 wk
after MI, 94%
after 24 wk. No
difference between
groups
Low
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Table 8.II. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
% return-
to-work
(RTW) Results Quality
Hedba¨ck
1987 (27)
Sweden
To compare
the outcome
of a rehabilitation
programme after
myocardial
infarction with
standard treatment
Cohort study
1978 – 1980
All patients
v65 y
admitted
for acute
myocardial
infarction
305: 148
vs 157
57.3 vs
57.2
Return at 1, 2,
and 5 y after
infarction
Combined
cardiac
rehab-
programme
vs standard
treatment
51.8 vs
27.4%
No difference after
1 y (61.5 vs 56.5%,
but after 2 y (64.9
vs 43.1%) and
after 5 y
Low
Herlitz
1994 (16)
Sweden
Outcome of
morbidity and
RTW 1 y after
myocardial
infarction
Prospective
cohort study
1986 – 1987
All patients
admitted
to a specific
hospital for
myocardial
infarction
921 72, 16 – 98 Percentage
RTW of total
groups, and of
groups v65 y
Standard
medical
treatment
49% Under 65: 37%
full-time, 12%
part-time. Age
and infarction size
predicts RTW
Low
Maeland
1986 (17)
Norway
RTW 6 months
after infarction
in relation to
job before,
demographic
factors and
disease severity
Prospective
cohort study
1978 – 1980
Consecutive
group
patients after
infarction
v67 y
249 v67 RTW and
sick leave
6 months
after
myocardial
infarction
Standard
medical
treatment
72.7% See below. Residence,
age, education, stress
at work and with
complications
predict RTW
Low
Maeland
1987 (18)
Norway
To study RTW
6 months after
infarction vs
psychological
variables
Prospective
cohort study
1978 – 1980
Consecutive
group
patients after
infarction v67 y
249 v67 RTW and
sick leave
6 months
after
myocardial
infarction
Standard
medical
treatment
72.7% 73% RTW half
a year after
infarction,
25% remained
sick listed.
Perception, anxiety,
depression at hospital
predictors for
RTW
Low
Sick leave due to coronary artery disease or stroke 193
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Table 8.II. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
% return-
to-work
(RTW) Results Quality
Petrie 1996
(19) New
Zealand
RTW 6 months
after infarction
in relation to
patient’s perception
and participation
in cardiac
rehabilitation
Prospective
cohort study
1993
Consecutive
group
patients
after first
infarction v65 y
143 53.2¡8.4 RTW and sick
leave 3 and
6 months after
myocardial
infarction
Participation
a combined
rehabilitation
programme
58% 40/105 RTW after
6 wk, 76 after
6 months. The
patient’s initial
perception of
disease severity
determined the
prognosis
Low
Pilote 1992
(28) USA
RCT of targeted
advice based on
stress-EKG in
men after
uncomplicated
myocardial
infarction
RCT
1987 – 1989
Consecutive
group
patients after
infarction
¡60 y, working
before
infarction
187: 95
vs 92
50 vs
51¡6
vs 7
Via mailed
survey/
telephone:
RTW 1,3 and
6 months after
infarction
Early stress
test and
targeted
advice on
sick-leave
duration to
primary care
91 vs
95%
No difference
after 6 months,
but more patients
in intervention
group to coronary
intervention.
Patients without
resid. ischaemia at
work sooner (38 days)
in intervention
group than standard
treatment (65 days)
Low
Smith
1988(20)
USA
To study RTW
1 y after infarction
vs work before,
demographic
factors, and
degree of severity
of the disease
Prospective
cohort study
1984 – 1985
Consecutive
group
patients
after first
infarction v70 y
151 51.2¡8 Via mailed
survey/
telephone:
RTW 4 and
12 months after
infarction
Standard
medical
treatment
72% Educational
level, physical
demands of
job, perception
of disease and
economic motives
mainly determine
RTW
Low
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Table 8.II. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
% return-
to-work
(RTW) Results Quality
Soejima
1999 (21)
Japan
To study RTW
8 months after
MI in relation to
psychological and
clinical variables
in Japan
Prospective
cohort study
1992 – 1996
First-time MI,
men ¡65 y, in
full-time job
previously
134 54.3 Via mailed
survey/
telephone:
RTW on
average
8 months after
infarction
Standard
medical
treatment
82.9% Age, depression,
perception of
health, difficulty
in managing
stress but not
infarction size
determine RTW
Low
Wiklund
1985 (22)
Sweden
To study factors
that predict RTW
2 and 12 months
after MI
Prospective
cohort study
1978 – 1980
Male patients
v60 y,
working
before MI
201 v60 Via mailed
survey/
telephone:
return-to-work
2 and
12 months
after MI
Standard
medical
treatment
75% Importance of
psychological
factors in
RTW. Patients
indicated causal
association
between work
and myocardial
infarction
Low
Sick leave due to coronary artery disease or stroke 195
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Table 8.III. Studies included – PCI & CABG
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
%
return-
to-work
(RTW) Results Quality
Boulay 1982
(41) Canada
To compare
a rehabilitation
programme vs
standard
treatment
after CABG,
predictors for
RTW
Prospective
cohort study
1978 – 80
Men
v60 y,
working
before CABG
121: 59
vs 62
48.4
vs 50.7
Via an
examination
one year
after CABG
Combined
rehabilitation
programme vs
standard
after care
92 vs
89%
No difference between
the groups. Length
of sick leave before
CABG, physical
strain at work, other
disease, education,
angina and symptom
duration were
predictive for RTW
Low
Boudrez
2000 (31)
Belgium
To study
RTW 1 year
after CABG in
relation to
psychological,
social and
clinical
variables.
Prospective
cohort study
1995 – 98
Consecutive
group patients
after CABG
v60 y
137 50¡6 Via mailed
survey/telephone:
return-to-work
12 months
after CABG
Opportunity
to participate
in rehabilitation
programme
(48.5%)
80.8% Positive expectation
about work,
physical strain,
stress and other
somatic symptoms
were predictors
Low
Bryant 1989
(32) England
Predictors for
RTW after
CABG
Prospective
cohort study
1980s
Consecutive
group men after
CABG ¡65 y
79 ¡65 y Via patient
interview 3 and
12 months
after CABG
CABG 57% 37% RTW at
3 months, 57% at
one year. Work before
CABG and social
class predictors
Low
Caine 1991
(46) England
Predictors for
RTW after
CABG
Prospective
cohort study
1982 – 1984
Consecutive
group patients
after CABG
v60 y
100 51¡6 Via mailed
survey/telephone:
RTW 3 and
12 months
after CABG
CABG 73% Predictors:
working before
operation, length
of waiting time and
remaining physical
limitations
Low
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Table 8.III. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
%
return-
to-work
(RTW) Results Quality
Engblom
1994 (42)
Finland
RCT of
cardiac
rehabilitation
vs standard
treatment
after CABG
with RTW as
main parameter
RCT
1986 – 1987
Consecutive
group men
after CABG
v65 y
125: 66
vs 59
52 vs
51¡6
Via patient
interview 6 and
12 months
after CABG
Combined
rehab
programme
(exercise,
psychosocial
support) vs
standard
treatment
56 vs
38%
Patient views on
work capacity,
functional class,
desire to RTW
and sick-leave
duration before
CABG
were predictors
Low
Fitzgerald
1989 (33)
USA
Predictors for
early RTW
after first-time
and successful
PCI
Prospective
cohort study
1980s
Patients
successful
first-time PCI,
working before
the intervention
82 52¡9 Questionnaire
and patient
interview at 1
and 6 months
after PCI
PCI 87% At 1 month 59%
RTW, 87% after
6 months. Patients
with high self-
efficacy RTW earlier
Low
Gehring
1988 (34)
Germany
Predictors for
RTW after
CABG
Prospective
cohort study
1980 – 1983
Consecutive
series of
patients after
CABG, working
before op
249 53.4 Questionnaire
16 months after
angio and on
average 1 year
after CABG
CABG 44.3% 37% (disability)
pension and 17%
sick listed after
1 year. Predictors:
symptom free and
work capacity
post-op, degree of
revascularisation;
also work-related
factors
Low
Sick leave due to coronary artery disease or stroke 197
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Table 8.III. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
%
return-
to-work
(RTW) Results Quality
Hlatky
1998 (36)
USA
RCT of PCI vs
CABG in
patients who
had a job
before the
intervention,
subgroup from
BARI
RCT
1988 – 1991
Patients who
worked before
PCI/CABG
409: 192
vs 217
not
available
During 4 years,
every third
month detailed
info on type
and level
of work
PCI versus
CABG (part
of BARI study)
82 vs
82%
PCI patients
on average returned
after 4.9 wk vs CABG
patients after 10.9 wk
Low
Hofman-
Bang
1999 (43)
Sweden
Cardiac
rehabilitation
at special rehab
centre vs
standard
treatment
after PCI
RCT
1993 – 1995
Patients from
a consecutive
series successful
PCI v65 y,
working before
the intervention
87: 46
vs 41
53¡7 Patient
questionnaire
1 and 2 y after
randomisation
Stay at
rehabilitation
centre incl
long-term
follow-up vs
standard
treatment
74 vs
78%
After 2 years: 68 vs
61% RTW. No
significant differences
in RTW or quality
of life
Low
Holmes
1984 (37)
USA
RTW in
3 groups
post-PCI:
successful vs
unsuccessful
with later
CABG vs
unsuccessful
with later
conservative
therapy
Cohort
study
1979 – 1982
Patients after
PCI: successful
vs unsuccessful
zCABG vs
unsuccessful z
med therapy
1 150 53.7 Questionnaire
on average
18 months
after PCI
CABG or
conservative
therapy if PCI
unsuccessful.
No
randomisation
70.4
vs
65.4
vs
61.8%
In the group
v60 y 81 – 86%
RTW. On successful
PCI RTW after
average 7 days,
after CABG 73
days, after
conservative
therapy 13 days
Low
198 J Perk and K Alexanderson
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Table 8.III. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
%
return-
to-work
(RTW) Results Quality
Janzon
2002(45)
Sweden
RCT of
invasive vs
non-invasive
treatment for
unstable
coronary
disease
RCT
1996 – 1999
Patient with
unstable
coronary
disease: invasive
vs non-invasive
933: 464
vs 469
37 – 65 Loss of working
days before
RTW as part of
health economic
analysis
Early
angiography
vs standard
conservative
examination
process
not
available
Sick leave on
average 102 days for
the invasive part vs
122 for the
conservative part
Low
Laird-Meeter
1989 (38)
Netherlands
Comparison
between non-
randomised
groups of PCI
and CABG
patients as
regards RTW
Cohort
study
1983 – 1984
Men v60 y
after PCI
or CABG
125
vs 94
51 vs
52¡6
Via mailed
survey/telephone:
return-to-work
1 y after PCI
or CABG
PCI or CABG
depending on
indication,
non-
randomised
96 vs
83%
53/55 PCI-patients
RTW, 49/59 CABG
patients. Predictors:
work ability before
PCI/CABG, age,
remaining angina
after op
Low
Lundbom
1992 (35)
Norway
Predictors for
RTW after
CABG
Prospective
cohort
study
1983 – 1985
All survivors
CABG patients
with job
before CABG
196 57.8:
36 – 69
Median follow-
up with
questionnaire
after 32 mo
(19 – 52)
Standard
treatment
49% Sick-leave duration
and waiting time
before CABG
affects RTW,
as does age, type
of job, duration of
disease history and
previous infarction
Low
Mark, 1994
(39) USA
Observation
study of
patients
after coronary
angio treated
with PCI,
CABG,
or medication
alone
Prospective
cohort study
1986 – 1990
Consecutive
group for
coronary angio,
v65 y, with job
before the study
1252: 312
PCI vs
449
CABG vs
491 med.
54:
46 – 60
Via mail
survey/
telephone:
RTW 12
months
after angio
3 groups:
PCI, CABG,
or conservative
therapy
84 vs
79 vs
76%
No significant
differences in
1-year follow-up.
Subgroup analysis:
RTW median 18 d
after PCI, 54 d
after CABG and
14 d for medical
treatment alone
Low
Sick leave due to coronary artery disease or stroke 199
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Table 8.III. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
%
return-
to-work
(RTW) Results Quality
McGee 1993
(40) Ireland
Comparison
between non-
randomised
groups of PCI
and CABG
patients
regarding
RTW
Prospective
cohort study
1989 – 1991
Consecutive
group
patients after
PCI vs CABG
119 PCI
vs 112
CABG
53.9¡7.3
vs 55.9¡5
Via mail
survey/
telephone:
RTW 6 – 18
mo after op
2 groups:
PCI or
CABG, non-
randomised
68 vs
59%
No significant
differences but PCI
yielded higher percent
early RTW: 8 wk
post-op: 39 vs 12%
Low
McKenna
1994 (13)
Australia
Observation
study of
patients
after PCI
Prospective
cohort study
1990 – 1991
Consecutive
group
patients after
uncomplicated
PCI
209 56: 30 – 78 Home visit or
mail survey
6 – 8 wk after
PCI and 1 y
after PCI
PCI 79% 119 working before.
73% back at
work in control
6 – 8 wk, median
time 25 d. Median for
return to normal
social life 14 d.
Medium
Noyez
1999 (29)
Netherlands
Long-term
follow-up
of younger
patients
after CABG
Prospective
cohort study
1989 – 1995
Consecutive
group patients
after CABG,
v45 y
167 41.7¡3 Register,
questionnaire
and telephone,
follow-up up
to 10 y
CABG 59.5% 131 in normal job
before, only 78
of these RTW
Low
Perk
1990 (44)
Sweden
Case-control
study of
cardiac
rehabilitation
after CABG
Case-control
1980 – 1985
Consecutive
group patients
after CABG vs
matched control
patients from
region
147: 49
vs 98
57¡7
vs 57¡7
Data via patient
visits, records
and surveys
Combined
cardiac
rehabilitation
programme vs
standard
treatment
59 vs
64%
No difference
between the
groups. In both
groups long wait
for CABG and
long sick leave
before operation
Low
Pocock 1996
(14) England
Compare RTW
up to 3 years
after PCI or
CABG in RCT
RCT
1988 – 1991
Participants in
RITA trial:
sub-study of
men ¡60 y.
PCI
vs CABG
963: 483
PCI vs
480 CABG
v60 Patient
interview and
questionnaire
after 1, 6, 12,
24, and 36 mo
PCI vs CABG
in cases where
anatomy was
comparable
for both
interventions
48.2
vs
52.3
%
No difference
3 years after
operation. However,
differences in early
RTW: PCI: 25 vs 39%
1 vs. 2 mo post-op;
CABG only 9% 2 mo
post-op No difference
5 months after op
Medium
200 J Perk and K Alexanderson
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Table 8.III. (Continued)
Author
Publ year
[Ref no.]
Country Aim
Type of study
Year(s) data
collected
Focus of
study n
Mean age
distribution
Type of sick
leave data Intervention
%
return-
to-work
(RTW) Results Quality
Skinner 1999
(30) England
5-year follow-up
of consecutive
patients after
CABG
Prospective
cohort study
1988 – 89
Consecutive
series of
patients
after CABG
353 57.2¡7.3 Patient visits
after 3, 6, 12
and 60 mo
CABG 84% 123 working before:
36% RTW after
3 mo, 84% after one
year and 49% after
5 years
Low
The BARI
Investigator
1997
(12) USA
5-year follow-up
of patients
randomised to
PCI or CABG
RCT
1988 – 1991
Patients included
in BARI study;
only those
working before
PCI/CABG
801: 374
PCI vs
427 CABG
61.8
vs 61.1
Patient visits
after 4 – 14 wk,
6 mo, 12 mo,
thereafter
annually
to 5 y
PCI versus
CABG
69 vs
72%
At visit 4 – 14 wk:
55% PCI RTW vs
36% CABG. No
differences at later
measurement points
Medium
Sick leave due to coronary artery disease or stroke 201
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