Returning to Work: a Forgotten Aspectof Rehabilitationfor Heartfailure?

Returning to work: a forgotten aspectof rehabilitationfor heartfailure?

MartinRCowieMD MSc

Professorof Cardiology,Imperial CollegeLondon (RoyalBrompton Hospital)

Keywords:Editorials;heartfailure; employment;rehabilitation

Correspondenceto:

MartinRCowieMD MScFRCPFRCP(Ed)FESCClinical Cardiology

NationalHeartand Lung InstituteImperial CollegeLondonDovehouseStreet

LondonSW3 6LYUnited Kingdom

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“Healthisa stateofcompletephysical,mental and socialwell-being and notmerely the absenceofdisease orinfirmity”

For thepast60years, the WorldHealth Organizationhasdefinedhealth in thisway.1Withadvancesin therapy,heartfailure(HF) can nowbeconsidered tobea chroniccondition withwhichmanyindividuals will liveforsome, if notmany,years.Reducing morbidity and improvingqualityoflife areimportant therapeuticaims.2,3 Traditionally,returning individuals toamoreoptimalstateofhealthwas theprovinceofcardiacrehabilitation (CR)programs -initiallyfocusedon patientsaftermyocardial infarction or coronaryarterybypasssurgery–butnowopenedmorewidelyto thoseafteranycoronaryintervention and,at last,tothosewithHF. At thecoreofCR programs is thedesiretoreturn individualstotheiroptimalphysical,mental,medical,psychological,social,emotional, sexual,vocational,and economic status.4

When reading HFclinicalguidelines onecould beforgiven forthinkingthat nopatientwith heartfailure wasin employment,orwould seekemployment.Inthe USA,an AmericanHeartAssociation(AHA)PresidentialAdvisory was issued in 2011 calling for amulti-prongedefforttoincreasethe lowreferralratesto cardiacrehabilitation/secondaryprevention programsafter acardiacevent.5Thisadvisoryspecificallymentionedvocationalcounselling.ThemostrecentAHA/American College of Cardiology HFguidelineawards aClass IIalevelrecommendation(‘it is reasonableto offer’) was madeforrehabilitation,2although returntoworkis notlisted asa potential benefit.The2016 HFguidelinesfromtheEuropean Society ofCardiologydo notdiscussoccupationalissues –although the recommendation ismadefora‘seamlesssystem ofmultidisciplinarycare thatembracesboth thecommunityand hospital’andmentionismadeofthevalue ofa‘socialworker’.3Even moredetailedguidelineson heartfailurediseasemanagementprogramsgoasfar asto labelheartfailurea ‘cardio-geriatricsyndrome’,withnoreferenceto vocationalrehabilitation.6This isdespitethefactthat inthe UK,a typicalnorthernEuropean country,14%ofpeopleadmitted tohospitalwith heartfailurearelikelytobebelowtheage of65.7

Even ignoring thepersonalcostofneverreturning towork- theeconomiccosttosocietyis large. InthemostrecentAHAupdate, theannualcostof HFin theUSA wasestimatedtobe$30.7billion.8Ofthistotal,68%wasattributable to directmedicalcostsbut an additional$9.8billionrelated toindirectcostsoflostproductivityfrommorbidityandprematuremortality.9

ThenovelanalysisbyRørthandcolleagues in thisissue ofCirculation throws alloftheseissuesintosharprelief.10Theyreportthe returnto work after afirsthospitalization forheartfailure inDenmarkfrom1997-2012.Denmarkis able to linknationalhealthand administrativeregistriesthrough anindividual’suniquepersonalidentification number,therebyallowingtrackingofvital status,healthcare utilization,drug prescription,and welfarepayments.

Rørthandcolleaguesfollowed acohortof individualsaged 18-60yearsat thetimeoftheir firsthospitalization forheart failurewho werealso employed(or atleastavailableforwork) atthetimeof thatadmission.During afouryearfollow-up periodnoneof theseindividualscrossedthe officialretirementageforDenmark (65years).Datawerecollectedon co-morbiditiescoded during anyhospitalization prior to, and including, the indexevent.

In thiscohort,themortality at12monthsafterdischarge was 7%–butonly68%returnedtotheworkforce.Thoseaged18-30werethreetimesmorelikelytoreturnto workthan thoseaged51-60.Fewclinicalvariableswereavailableforanalysis,but thosemostlikelytoreturntoworkwereyoungermen with higher educationalattainment(andhigherincome) - perhapsbecausetheir jobswereless likelytorequirephysical exertionorbecause therewasmorechoiceavailable, ortheir

expectationswerehigher.A historyofstroke,diabetes,chronickidney disease,chronicobstructivepulmonarydisease,or cancerreducedthechancesof returning to work –butahistoryofhypertension,coronaryarterydisease,oratrial fibrillation didnot. A longerinitialadmissionwasstronglyassociated witha lowerprobability of returning to work- presumablyrelated totheseverityof diseaseor presenceofco-morbidity.

Ofthe 87% of individuals who didreturn to work forat leastsometimemore thanhalfdid so‘shortly’afterhospitalization,and 75%by6months. However,retention in theworkforcewas nothigh – ofthosewhoreturnedto workby12months52%weredetached atsomepointduring the subsequent3years, andevenallowing for sickness leaveforupto 12weeks,38%weredetachedby3years.Keeping individualswith heartfailure inwork isobviouslychallenging.

Interestingly,theprescription of angiotensinconverting enzymeinhibitors or angiotensin receptorblockers,beta-blockersor digoxin wereassociatedwithan increasedlikelihoodof returntowork(presumablyreflecting a patientwhoiswell-treatedand whoisableto toleratethesedrugs)buttaking loop diureticsor analdosterone antagonistwereassociatedwith a lowerrateof returntowork–presumablyreflecting patientswith greaterdiseaseseverity.

Theauthorsspeculatethatlackof returnto workmaybeduetothefunctionallimitationsofthediseaseor co-morbidities,orthatitmaybeduetothepsychologicaleffectsofaHF diagnosis. It ispossiblethatthehealthcareteamsinvolved withsuchpatientsdonot oftenconsider a returntoworkpossible,areconcerned aboutthe risks,or lackcompetence invocationalcounselling orrehabilitation.It is notknownhowmanyofthe patientsin thisstudywereoffered (ortookup) aformalCRprogram,orwhetherworkplaceoccupationalhealth serviceswereinvolved. Manyquestionsremainunanswered, and it islikelythatattention is required ateach point inthejourneyfromhospitalization topotential returnto work,and from each stakeholderinvolved in thosetransitions.Ultimately,givingan individual a badgeof ‘heartfailure’maytriggerthatindividual, theirfamily,andtheiremployertoassume that workisnolongerpossible.RecentpublicationsfromoneSwedishcross-sectionalsurvey suggestthatpositiveencounterswith healthcareprofessionalsand‘social insuranceofficers’areassociatedwith a higherperception oftheabilitytoreturntowork.

Thoseon lowerincome inthissurveytendedtohavelowerperceptionsoftheirlikelihoodofreturningto work,and hadlesspositiveencounterswithsuch professionals.11,12.

Welcome asthenewdataare, isthe situation inDenmarklikelytoapplytoothercountriesoutsideNorthernEurope? Denmark is asmall,wealthycountryin Northern Europe,withhigh taxation,lowunemployment and high public socialexpenditure.13Thereisa nationalhealth servicefundedbytaxation. Incontrast, the USAismuchlarger,butisevenwealthierand with lowerunemployment. In contrastto Denmark, thetaxrateislowerbutmuchmore isspent onhealthcare(largelyduetoamuchlargerprivatecontribution)butpublic socialexpenditureisconsiderablylower.Thepressuretoreturnto workmaythereforebehigher in such asetting,particularlyifemploymentbringsbetter (ormoreaffordable)healthcareaccess.Thesituationislikelytobemarkedlydifferent in lessaffluent countries,where anevenhigherproportionofindividuals withHFmaybeofworking agebut likelywith lowerincomeand educationalachievements.Further researchis required,butpoliciesand programsto optimize return to work arelikelytolookverydifferent indifferentcountries.

Referralof allHFpatientstoa CRprogram shouldincreasethe chancesof returnto work–butonly ifthat programincludesappropriatevocationalcounselling andskills.Referraltooccupationalhealthservices,providedtheyhave an up-to-dateconceptofheartfailure and its therapy,maybeinvaluable.Multiprofessional/multidisciplinarycare teams willbeessentialforthosewithco-

morbidities–such asa young personwhosurvivescancerbuthasdevelopedHFas a result ofoncological drugs.Evenmorefundamentally,at each contactwitha personof working age(and theirfamily),thetopicshould beraised;legitimizing thisforboth patient and professional. Bettercommunication betweenthehealthcareteam and theemployermayalsoimprove theoutcome:return toworkneed notbe ‘allornone’;staging is entirelypossibleas maybereallocationof heaviermanualtasks. If theopportunitytoaddresstheseissuesduring hospitalization and in the earlyperiod thereafter ismissed, returnto workmayneverbeachieved. Thosewith lowereducationalattainment and lowerincome will strugglemoreandare likelytorequireadditionalsupport.

Ultimately,HFprogramsshould bejudgednotonlyonthe useof disease-modifying therapy or lowreadmissionrates,butonapatient’squality of lifeandvocationalstatus. If a patient with heartfailure is nolongerworking–whynot? And whatcan thehealthcareteam do tooptimizethechancesof returntowork?These are questionswe should beasking ourselvesmoreoften.

References

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SourcesofFunding

Dr Cowie is supported bytheNationalInstituteforHealth Research CardiovascularBiomedicalResearchUnitat theRoyalBrompton Hospital,London, UK.

Disclosures

None