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Meta-Analysis
. 2019 Mar 14;3(3):CD010748.
doi: 10.1002/14651858.CD010748.pub2.

Interventions to support return to work for people with coronary heart disease

Janice Hegewald  1 , Uta E Wegewitz, Ulrike Euler, Jaap L van Dijk, Jenny Adams, Alba Fishta, Philipp Heinrich, Andreas Seidler
Affiliations
Meta-Analysis

Interventions to support return to work for people with coronary heart disease

Janice Hegewald et al. Cochrane Database Syst Rev. .

Abstract

Background: People with coronary heart disease (CHD) often require prolonged absences from work to convalesce after acute disease events like myocardial infarctions (MI) or revascularisation procedures such as coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Reduced functional capacity and anxiety due to CHD may further delay or prevent return to work.

Objectives: To assess the effects of person- and work-directed interventions aimed at enhancing return to work in patients with coronary heart disease compared to usual care or no intervention.

Search methods: We searched the databases CENTRAL, MEDLINE, Embase, PsycINFO, NIOSHTIC, NIOSHTIC-2, HSELINE, CISDOC, and LILACS through 11 October 2018. We also searched the US National Library of Medicine registry, clinicaltrials.gov, to identify ongoing studies.

Selection criteria: We included randomised controlled trials (RCTs) examining return to work among people with CHD who were provided either an intervention or usual care. Selected studies included only people treated for MI or who had undergone either a CABG or PCI. At least 80% of the study population should have been working prior to the CHD and not at the time of the trial, or study authors had to have considered a return-to-work subgroup. We included studies in all languages. Two review authors independently selected the studies and consulted a third review author to resolve disagreements.

Data collection and analysis: Two review authors extracted data and independently assessed the risk of bias. We conducted meta-analyses of rates of return to work and time until return to work. We considered the secondary outcomes, health-related quality of life and adverse events among studies where at least 80% of study participants were eligible to return to work.

Main results: We found 39 RCTs (including one cluster- and four three-armed RCTs). We included the return-to-work results of 34 studies in the meta-analyses.Person-directed, psychological counselling versus usual careWe included 11 studies considering return to work following psychological interventions among a subgroup of 615 participants in the meta-analysis. Most interventions used some form of counselling to address participants' disease-related anxieties and provided information on the causes and course of CHD to dispel misconceptions. We do not know if these interventions increase return to work up to six months (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.84 to 1.40; six studies; very low-certainty evidence) or at six to 12 months (RR 1.24, 95% CI 0.95 to 1.63; seven studies; very low-certainty evidence). We also do not know if psychological interventions shorten the time until return to work. Psychological interventions may have little or no effect on the proportion of participants working between one and five years (RR 1.09, 95% CI 0.88 to 1.34; three studies; low-certainty evidence).Person-directed, work-directed counselling versus usual careFour studies examined work-directed counselling. These counselling interventions included advising patients when to return to work based on treadmill testing or extended counselling to include co-workers' fears and misconceptions regarding CHD. Work-directed counselling may result in little to no difference in the mean difference (MD) in days until return to work (MD -7.52 days, 95% CI -20.07 to 5.03 days; four studies; low-certainty evidence). Work-directed counselling probably results in little to no difference in cardiac deaths (RR 1.00, 95% CI 0.19 to 5.39; two studies; moderate-certainty evidence).Person-directed, physical conditioning interventions versus usual careNine studies examined the impact of exercise programmes. Compared to usual care, we do not know if physical interventions increase return to work up to six months (RR 1.17, 95% CI 0.97 to 1.41; four studies; very low-certainty evidence). Physical conditioning interventions may result in little to no difference in return-to-work rates at six to 12 months (RR 1.09, 95% CI 0.99 to 1.20; five studies; low-certainty evidence), and may also result in little to no difference on the rates of patients working after one year (RR 1.04, 95% CI 0.82 to 1.30; two studies; low-certainty evidence). Physical conditioning interventions may result in little to no difference in the time needed to return to work (MD -7.86 days, 95% CI -29.46 to 13.74 days; four studies; low-certainty evidence). Physical conditioning interventions probably do not increase cardiac death rates (RR 1.00, 95% CI 0.35 to 2.80; two studies; moderate-certainty evidence).Person-directed, combined interventions versus usual careWe included 13 studies considering return to work following combined interventions in the meta-analysis. Combined cardiac rehabilitation programmes may have increased return to work up to six months (RR 1.56, 95% CI 1.23 to 1.98; number needed to treat for an additional beneficial outcome (NNTB) 5; four studies; low-certainty evidence), and may have little to no difference on return-to-work rates at six to 12 months' follow-up (RR 1.06, 95% CI 1.00 to 1.13; 10 studies; low-certainty evidence). We do not know if combined interventions increased the proportions of participants working between one and five years (RR 1.14, 95% CI 0.96 to 1.37; six studies; very low-certainty evidence) or at five years (RR 1.09, 95% CI 0.86 to 1.38; four studies; very low-certainty evidence). Combined interventions probably shortened the time needed until return to work (MD -40.77, 95% CI -67.19 to -14.35; two studies; moderate-certainty evidence). Combining interventions probably results in little to no difference in reinfarctions (RR 0.56, 95% CI 0.23 to 1.40; three studies; moderate-certainty evidence).Work-directed, interventionsWe found no studies exclusively examining strictly work-directed interventions at the workplace.

Authors' conclusions: Combined interventions may increase return to work up to six months and probably reduce the time away from work. Otherwise, we found no evidence of either a beneficial or harmful effect of person-directed interventions. The certainty of the evidence for the various interventions and outcomes ranged from very low to moderate. Return to work was typically a secondary outcome of the studies, and as such, the results pertaining to return to work were often poorly reported. Adhering to RCT reporting guidelines could greatly improve the evidence of future research. A research gap exists regarding controlled trials of work-directed interventions, health-related quality of life within the return-to-work process, and adverse effects.

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Conflict of interest statement

Janice Hegewald: None known.

Uta Wegewitz: I was employed at the Federal Institute for Risk Assessment (Germany) from 2007 to 2010. Currently I am employed by the Federal Institute for Occupational Safety and Health (BAuA) in Germany.

Ulrike Euler: I received payment for lectures in occupational epidemiology at the Berlin School of Public Health.

Jaap van Dijk: None known.

Jenny Adams: None known.

Alba Fishta: None known.

Philipp Heinrich: None known.

Andreas Seidler: I received payment for lectures in occupational epidemiology at the Berlin School of Public Health.

Figures

1
1
PRISMA flow diagram of study selection process
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study
3
3
Funnel plot of comparison 2. Psychological interventions (including health education) vs usual care, outcome: 2.3 proportion returning to work (short term)
4
4
Funnel plot of comparison 4. Physical conditioning interventions vs usual care, outcome: 4.3 proportion returning to work (medium term)
5
5
Funnel plot of comparison 5. Combined conditioning interventions vs usual care, outcome: 5.3 proportion returning to work (medium term)
6
6
Funnel plot of comparison: 5 combined conditioning interventions vs usual care, outcome: 5.6 proportion returning to work (long term)
1.1
1.1. Analysis
Comparison 1 Psychological interventions (including health education) vs usual care, Outcome 1 Proportion returning to work (all studies).
1.2
1.2. Analysis
Comparison 1 Psychological interventions (including health education) vs usual care, Outcome 2 Proportion returning to work short term (< 6 months) by CHD severity.
1.3
1.3. Analysis
Comparison 1 Psychological interventions (including health education) vs usual care, Outcome 3 Proportion returning to work medium term (6 months‐1 year) by CHD severity.
1.4
1.4. Analysis
Comparison 1 Psychological interventions (including health education) vs usual care, Outcome 4 Mean time until return to work (days).
2.1
2.1. Analysis
Comparison 2 Work‐directed counselling vs usual care, Outcome 1 Proportion returning to work (all studies).
2.2
2.2. Analysis
Comparison 2 Work‐directed counselling vs usual care, Outcome 2 Mean time until return to work (days).
2.3
2.3. Analysis
Comparison 2 Work‐directed counselling vs usual care, Outcome 3 Adverse effects: cardiac deaths.
2.4
2.4. Analysis
Comparison 2 Work‐directed counselling vs usual care, Outcome 4 Adverse effects: reinfarctions.
3.1
3.1. Analysis
Comparison 3 Physical conditioning interventions vs usual care, Outcome 1 Proportion returning to work (all studies).
3.2
3.2. Analysis
Comparison 3 Physical conditioning interventions vs usual care, Outcome 2 Proportion returning to work medium term (0.5‐1 year) by CHD severity.
3.3
3.3. Analysis
Comparison 3 Physical conditioning interventions vs usual care, Outcome 3 Mean time until return to work (days).
3.4
3.4. Analysis
Comparison 3 Physical conditioning interventions vs usual care, Outcome 4 Mean time until return to work (days) by physically strenuous workgroup.
3.5
3.5. Analysis
Comparison 3 Physical conditioning interventions vs usual care, Outcome 5 Adverse effects: cardiac deaths.
3.6
3.6. Analysis
Comparison 3 Physical conditioning interventions vs usual care, Outcome 6 Adverse effects: reinfarctions.
4.1
4.1. Analysis
Comparison 4 Combined interventions vs usual care, Outcome 1 Proportion returning to work (all studies).
4.2
4.2. Analysis
Comparison 4 Combined interventions vs usual care, Outcome 2 Proportion returning to work medium term (6 months‐1 year) by CHD severity.
4.3
4.3. Analysis
Comparison 4 Combined interventions vs usual care, Outcome 3 Proportion returning to work medium term (6 months‐1 year) by physically strenuous work.
4.4
4.4. Analysis
Comparison 4 Combined interventions vs usual care, Outcome 4 Proportion returning to work medium term (6 months‐1 year) by sex.
4.5
4.5. Analysis
Comparison 4 Combined interventions vs usual care, Outcome 5 Mean time until return to work (days).
4.6
4.6. Analysis
Comparison 4 Combined interventions vs usual care, Outcome 6 Health‐related quality of life.
4.7
4.7. Analysis
Comparison 4 Combined interventions vs usual care, Outcome 7 Adverse effects: total mortality.
4.8
4.8. Analysis
Comparison 4 Combined interventions vs usual care, Outcome 8 Adverse effects: reinfarctions.
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References to studies awaiting assessment

Franklin 2012 {published data only}
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References to ongoing studies

EXPERTIS {published data only}
    1. NCT02415075. Prevention of Reduced Employability With an Expert System With Telephone, Motivational Interviews Supporting Self‐management (EXPERTIS). clinicaltrials.gov/ct2/show/NCT02415075 (first received 14 April 2015).
LC‐REHAB {published data only}
    1. NCT01668394. Effect of Learning and Coping Strategies in Cardiac Rehabilitation ‐ Group Study (LC‐REHAB). clinicaltrials.gov/ct2/show/NCT01668394 (first received 20 August 2012).
MILESTONE {published data only}
    1. NCT01311323. Revascularization in Patients With Non‐ST‐Segment Elevation Acute Coronary Syndrome (NSTE‐ACS) With Multivessel and/or Unprotected Left Main Coronary Disease (MILESTONE). clinicaltrials.gov/ct2/show/NCT01311323 (first received 9 March 2011).
SATISFY‐SOS {published data only}
    1. NCT02032030. Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY‐SOS). clinicaltrials.gov/ct2/show/NCT02032030 (first received 09 January 2014).
SUSTAINCSX {published data only}
    1. NCT02002247. SodiUm SeleniTe Adminstration IN Cardiac Surgery (SUSTAIN CSX®‐Trial). (SUSTAINCSX). clinicaltrials.gov/ct2/show/NCT02002247 (first received 05 December 2013).
WARRIOR {published data only}
    1. NCT03417388. Women's IschemiA TRial to Reduce Events In Non‐ObstRuctive CAD (WARRIOR). clinicaltrials.gov/ct2/show/NCT03417388 (first received 31 January 2018).

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