Acute myocardial infarction (AMI) is a “life-threatening event that occurs when a blood vessel supplying the heart is suddenly blocked completely, threatening to damage the heart muscle and its functions.”1(p268) An AMI may be the first manifestation of coronary artery disease, but it can also occur in patients with established disease.
A significant number of persons of working age experience an AMI. Of the 650 000 Americans per year who experience a first AMI, approximately half are employed.2 Recommendations for time taken off from work following an acute coronary event were previously determined by concerns regarding infarct healing times, with many centers recommending a recovery period of 6 to 8 wk.3 More recent studies, however, have found no adverse effects in patients considered to be at “low risk” returning to full normal activities, including work at 2 wk after AMI.4 The return-to-work rate after AMI is known to be lower for women, older people, blue-collar workers with physically strenuous jobs, and individuals with psychiatric conditions.5
Returning to work can play a significant part in social readjustment after a coronary event. Cardiac rehabilitation programs are an integral part of recovery post-AMI, focusing on aerobic and strengthening exercise to assist with this transition.6 It is important to note, however, that returning to work following AMI is not a simple function of clinical or physical status; it can be influenced by multiple factors, including demographic, social, and psychological factors. Specifically, nonmedical factors such as level of education, previous job role, and job satisfaction are considered key factors of recovery post-AMI.7 Psychological factors such as depressed mood, motivation to return to work, patient beliefs and perceptions of their condition, and fear of negative consequences are also key predictors of whether or not a patient will indeed return to work.5
Interventions aimed at addressing these complex issues are often provided by nurses or allied health workers such as occupational therapists, social workers, psychologists, and counselors. In the acute hospital admission phase, and also within cardiac rehabilitation programs, these interventions may include the following: psychosocial interventions such as patient counseling, health education, stress management, relaxation strategies, and mobilization of social supports; vocational interventions such as advice on suitable modified duties, task modification, workplace modifications, liaison between employee and employer with a graded return-to-work (RTW) program, and subsequent referral to external vocational agencies.
At present, it is unknown how effective these interventions are with this population in the early phase of their recovery. The aim of this systematic review was to assess the available literature to determine whether psychosocial and vocational interventions delivered in the first 3 mo post-AMI are effective for improving work outcomes.
The search strategy aimed to find both published and unpublished studies. After an initial search for articles in MEDLINE, an analysis of the text words contained in the titles and abstracts and of the subject terms used to index these articles was conducted. A second search using all identified key words and subject terms was then undertaken across all included databases: MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycINFO.
The searches were based on the MEDLINE search strategy. CENTRAL, CINAHL, and PsycINFO searches were adapted as appropriate to the specifications for these databases. Gray literature and reference lists from relevant articles were also reviewed to identify additional articles. The search terms used are listed in the Supplemental Table (Supplemental Digital Content 1, available at http://links.lww.com/JCRP/A53), with limits applied as English, and clinical trials (randomized controlled trials [RCTs] including cluster RCTs, quasi RCTs, and controlled before-after studies). Full search strategies for each database are available on request from the corresponding author.
Studies were included if they involved psychosocial and/or vocational interventions (Table 1) for adults (age ≥18 years) with an AMI who were within the first 3 mo post-AMI. Participants should also have been employed (paid employment or self-employed) or participating in voluntary work or study prior to their AMI. Other inclusion criteria included the reporting of at least 1 RTW outcome including return to paid/unpaid employment, either full-time or part-time, to the previous job role or on modified duties. Return to work could be measured either as event data (eg, RTW rates) or time to event data (eg, time span between AMI and return to work). Secondary outcomes were voluntary work, return to study, and quality-of-life measures.
Studies were excluded using the following criteria: published in non-English language; not a clinical trial; or purely focused on exercise or pharmacological intervention. Other exclusion criteria included material only published as conference or abstract presentations.
Two authors (S.W. and L.O.B.) blinded to authors and journals independently screened titles and abstracts of all studies identified by the search and coded them as to be excluded or to be included. If an abstract was coded as the latter by either or both authors, the full text was retrieved for independent screening. We also recorded reasons for excluding particular studies. When 2 or more studies clearly resulted in multiple publications from the same participant group, the study with the longest follow-up and largest sample was included, and the others were excluded. If there were relevant missing data or uncertainties, we contacted the authors of the original articles. Data extracted for analysis pertained to study methods (design, duration, setting, and dropouts), participants (numbers, gender, diagnostic criteria, inclusion and exclusion criteria), interventions (types, duration, intensity, content of both intervention and control condition, and cointerventions) outcomes (description of primary and secondary outcomes specified and collected and at which time points these were reported). Any disagreements were resolved by consensus. This review was registered prospectively on PROSPERO International prospective register of systematic reviews (CRD42015016336).
ASSESSMENT OF RISK OF BIAS IN INCLUDED STUDIES
Two authors (S.W. and L.O.B.) independently assessed the methodological quality of the included studies, using the Cochrane Risk of Bias Tool,8 and any disagreement was discussed by all review authors to achieve a consensus. The risk of bias tool addresses 6 specific domains, namely sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other issues. Decision rules were specified to the assessor to assign a high risk, low risk, or unclear determination to each criterion.
MEASURES OF TREATMENT EFFECT
One author (L.O.B.) transferred data into Review Manager Version 5.2 software (The Nordic Cochrane Centre, The Cochrane Collaboration) and 2 authors (L.O.B. and S.W.) verified that data were entered correctly by comparing the data presented in the systematic review with the study reports. Where possible, outcome data for each study were entered into the data tables to calculate the treatment effects. Dichotomous outcome data were expressed as risk ratios (relative risk [RR]) with 95% CIs. For continuous variables, we used the mean difference when outcome measurements in all trials were made using the same scale. For continuous data with missing standard deviations, where possible, calculation of SD was performed using other statistics (eg, CIs). Where data were not available in an alternative form that allowed direct calculation, we used SD results from other studies to impute missing values as per the method described by Furukawa.9
The search yielded 1257 potentially relevant papers. After duplication removal and record screening of abstract and title, 35 full-text papers were retrieved. Of these, 18 papers were retained for final analysis. The flowchart for study selection is presented in Figure 1.
Characteristics of included studies are shown in Table 1 and the appraisal of risk of bias is presented in the Supplemental Figure (Supplemental Digital Content 2, available at http://links.lww.com/JCRP/A54). In all studies, it was difficult to achieve participant blinding due to the nature of the intervention. Method of random allocation, assessor blinding, concealed allocation, and losses to follow-up were inconsistently reported.
A total of 2815 individuals with AMI were involved across all studies, and the proportion of males was 88.8%. For most studies, the mean age of participants was mid to late 50s. All but 5 papers10–14 provided data on RTW rates or time to RTW. One study10 only presented results graphically; the author was contacted, however; as no additional data were supplied, it was excluded from the meta-analysis.
The usual care conditions were not described in 5 studies.14–19 Most others included follow-up with a local doctor and cardiac specialist11–13,20–22 and some provided controls with written materials13,23,24 or audiovisual materials relating to health (including diet and risk factors)25 or returning to work.26 One study returned controls to normal activity (including their previous job) at 6 wk post-AMI.10
The interventions (based on published reports) are summarized in Table 2. Regarding the content of the interventions, most studies reported providing counseling aimed at reducing participant anxiety regarding the health condition; reducing risks of future events by addressing diet, exercise, and smoking; and planning for RTW. Participant spouses or families were encouraged to attend in 8 studies.12–15,18–20,25,27 Two studies18,19 reported an occupational work evaluation that was a symptom-limited treadmill test followed by a counseling session conducted by the same nurse-clinician and cardiologist who administered the test. Five studies10,16,18,27,28 included telephone follow-up provided by an employment officer, a nurse rehabilitator, or social worker. According to the trial reports, ongoing workplace-based contact with the worker and employer (or supervisor) occurred in only 2 studies.16,20
Primary outcomes were the percentage of participants working at specified follow-up times or the time taken to RTW. Only 1 study measured hours worked per week (at 3 and 6 mo)25 and another measured the percentage of eligible weeks worked (also at 3 and 6 mo).26 None measured volunteer work or participation in vocationally oriented studies. All studies used patient self-report of work status. For the purpose of meta-analysis, interventions were classified as being either group or individual programs, and comparisons were made for RTW at 3, 6, and 12 mo post-AMI.
RETURN TO WORK AT 3 MO POST-AMI
Group counseling versus usual care
Four studies12,13,24,25 involving 290 participants were included in this analysis, which found no significant difference in the percentage of participants working at 3 mo (Figure 2).
Individual counseling versus usual care
There was a small significant difference favoring individual counseling over usual care in this analysis of 2 studies15,23 involving 104 participants (RR = 1.17; 95% CI, 1.00-1.37; P = .05) (Figure 3).
RETURN TO WORK AT 6 MO POST-AMI
Group counseling versus usual care
Results for this analysis, which included 3 studies21,24,25 and 311 participants, approached significance in favor of the control condition (RR = 0.86; 95% CI, 0.74-1.01; P = .06) (Figure 4).
Individual counseling versus usual care
There was no significant difference in RTW rates at 6 mo for individual counseling compared to usual care in this analysis involving 5 studies18,19,22,26,28 with 689 participants (Figure 5).
RETURN TO WORK AT 12 MO POST-AMI
Group counseling versus usual care
There was no significant difference in RTW rates at 12 mo for group counseling compared to usual care in this analysis involving 2 studies14,24 and 144 participants (Figure 6).
Individual counseling versus usual care
No significant difference was found in RTW rates at 12 mo for individual counseling compared to usual care in this analysis involving 2 studies16,17 and 236 participants (Figure 7).
MEAN NUMBER OF DAYS TO RETURN TO WORK
Six studies reported mean days to RTW11,16–20; however, none reported SD values. These were calculated from 1 study that supplied 95% CIs and the same SD was imputed for all other missing SD data. There was a statistically significant difference in favor of a counseling intervention (mean difference =−6.11 d; 95% CI, −6.95 to −5.26; P < .001) (Figure 8).
This systematic review aimed to assess the available literature to determine whether psychosocial and vocational interventions delivered in the first 3 mo post-AMI were effective for improving work outcomes including work participation and time to RTW. The majority of included studies were published prior to the year 2000 and were poorly or inconsistently reported, resulting in very low scores on the risk of bias assessment. Trials in this review assessed these interventions alone and also in combination with general practitioner follow-up and, in some cases, combined with exercise therapy interventions. All trials measured either time to RTW or participation for paid work at specific follow-up time points.
We found a small but significant improvement in RTW rates at 3 mo for people receiving individual counseling interventions when compared to usual care but no difference at 6 or 12 mo. We also found that people receiving some form of psychological or vocational counseling intervention (group or individual) returned to work 6.33 d sooner than those who received usual care, although this result needs to be interpreted with caution. All but 1 of the studies included in this specific analysis were conducted in the 1980s or 1990s, before some contemporary treatments for coronary heart disease, such as acute thrombolytic therapy, β-adrenergic blockers, and aggressive lipid management were routinely used, and the comparison intervention was either minimal contact with a physician or not described. Currently, many physicians in industrialized countries would refer patients with AMI to a cardiac rehabilitation program that includes prescribed exercise training and advice on modifiable risk factors, although participation rates remain around 30% to 40% in the first month post-AMI29,30; thus, comparison with physician-only follow-up may not be valid.
The precise mechanism(s) by which counseling may improve speed of RTW in AMI patients has not been fully explained but may be the result of better management of stress and identification and treatment of depressive symptoms, which have been shown to impede recovery, especially the ability to work.31,32 Counseling may also assist those who are more vulnerable to retrenchment, such as those in manual or semiskilled manual labor roles by providing career counseling, retraining, or negotiation of suitable duties with employers.33,34
IMPLICATIONS FOR CLINICAL PRACTICE
Much of the emphasis in recovery post-AMI is directed at improving physical fitness and addressing modifiable lifestyle risk factors. Specialized occupational therapists have been employed in some European cardiac centers, but a structured program for RTW is often lacking in most cardiac rehabilitation programs.35 It is recommended that a specific role be established within the multidisciplinary team (specialized nurse, occupational therapist, or physiotherapist) to gather relevant information from the patient and the workplace and a RTW plan should be negotiated between the patient, the cardiac rehabilitation service, and the employer.35 This is especially important for those patients most vulnerable to job loss such as women32 and people in manual labor work.
IMPLICATIONS FOR RESEARCH
Given the superior health and well-being associated with workforce participation,36 it is surprising that there are so few recent studies evaluating the impact of vocationally directed counseling in the first months post-AMI. Future studies should have a valid comparison group (eg, exercise-only cardiac rehabilitation; accurate measures of hours worked per week, as well as type of duties [such as, same as pre-AMI, modified duties, or different duties]; adequate follow-up; and reporting of adverse events to enable clinicians to identify the most effective intervention).
This systematic review has several potential limitations, most notably the poor methodological quality of many of the included trials. We limited this review to randomized or clinical controlled trials published in English, which could predispose our results to publication bias. In addition, only 4 of the included studies were published this century and medical management of AMI has improved significantly since 2000.
This review demonstrates that vocationally directed counseling may assist people to return to work sooner following AMI, possibly by identifying and addressing issues such as stress and depression in the early stages31 or by keeping communication channels open with pre-AMI employers. There was no difference in work rates at 6 or 12 mo. There are few recent high-quality studies in this field and compelling evidence supporting broad implementation of vocational counseling in the acute phase is still limited. There is also a clear need for current studies with valid comparison groups that include detailed and accurate measures of workforce participation in the first 2 years post-AMI.
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