Employment status among persons attending cardiac rehabilitation in a primary healthcare setting: A Danish cohort study

Abstract

Background:

Limited understanding exists regarding effective return-to-work strategies for persons participating in cardiac rehabilitation (CR).

Objective:

The aim of this study was to explore the association between CR completion and employment status at 6- and 18-months post-inclusion in CR within primary healthcare settings in the Central Denmark Region.

Methods:

A cohort study was conducted using data from a non-randomized clinical controlled trial involving persons with ischemic heart disease attending CR between August 1, 2018, and July 31, 2019, within the working age (18–65 years). Successful CR completion was defined as attending ≥75% of the program. Employment status was assessed at 6- and 18-months post-CR inclusion. Logistic and linear regression models, adjusted for potential confounders, were used for association analysis.

Results:

The study encompassed 244 participants, of whom 109 completed CR and 135 not. At 6 months’ follow-up, 65.9% of the study population were working, with 47.8% being CR completers and 52,2% non-completers. At 18 months’ follow-up, 69.3% of the participants were working, including 45.0% completers and 55.0% non-completers.

Conclusion:

The study found no statistically significant differences in employment status between persons who completed CR and those who did not, suggesting limited influence of CR attendance on subsequent employment outcomes.

Keywords

cardiac rehabilitation employment status ischemic heart disease primary healthcare

Introduction

Returning to work holds importance for persons coping with ischemic heart disease (IHD) both mentally and socially (Berg et al., 2013; Cauter et al., 2019; Warraich et al., 2018), while societal economic burden due to lost productivity remains substantial (Timmis et al., 2022). Of the approximately 126 million persons worldwide living with IHD, around one-third are of working age (Bernt Jørgensen et al., 2022; Khan et al., 2020), yet only two-thirds of this group manage to return to work within one-year post-hospital discharge (Bergvik et al., 2012; Sadeghi et al., 2022). With the prevalence of IHD expected to rise, facilitating persons return to work becomes imperative to enhance their health-related quality of life (Khan et al., 2020).

Cardiac rehabilitation (CR) stands as a class 1 recommendation for persons with IHD (Simon et al., 2018), yielding favourable outcomes including reduced cardiovascular events, heightened physical activity levels, and improved health-related quality of life (Carvalheira-Dos-Santos et al., 2019; Simon et al., 2018; Sunamura et al., 2020). Despite its inclusion of education and support geared towards fostering healthy lifestyle changes and facilitating return to work, CR guidelines lack specific strategies for supporting vocational reintegration (Ambrosetti et al., 2021; Cowie et al., 2019). This dearth of effective strategies poses challenges to healthcare providers in aiding persons return to work, compounded by the absence of consensus in the literature regarding CR's impact on employment status among attendees.

In hospital settings, studies indicate that approximately one-third of persons with IHD fail to return to work post-CR (Bernt Jørgensen et al., 2022; Khan et al., 2020), with findings on CR's long-term efficacy for improving return to work rates being inconclusive (Pedersen et al., 2023; Sadeghi et al., 2022; Salzwedel et al., 2019). Consequently, further investigation is warranted to elucidate CR's efficacy beyond the initial year and ascertain the role of healthcare interventions in bolstering vocational outcomes, especially as CR phase II (lifestyle change program) transitions from hospitals to primary healthcare settings across various nations (Christiansen, 2012; World Health, 2008). Such inquiries are indispensable for gauging CR's effectiveness and refining strategies to better support persons in their return-to-work endeavors.

Aim

Methods

Context of the study

This study draws upon data derived from a non-randomized clinical controlled trial (Pedersen et al., 2022), encompassing information from 10 out of 19 primary healthcare settings in the Central Denmark Region (Pedersen et al., 2022), all adhering to national CR guidelines (Cowie et al., 2019).

Adult persons diagnosed with IHD, discharged from hospital and referred to CR in one of the 10 primary healthcare settings between August 1, 2018, and July 31, 2019, were recruited. Initial interviews conducted by healthcare providers facilitated recruitment and obtained consent for subsequent questionnaire administration.

Organization of cardiac rehabilitation

Following a 2007 Danish structural reform, CR phase II transitioned from hospitals to primary healthcare settings (Christiansen, 2012). A 12-week CR program was instituted across the 19 primary healthcare settings in the Central Denmark Region in 2017, subsequently adopted by additional Danish primary healthcare settings. Core services entail promotion, prevention, and collaboration with the job centers. Healthcare providers refer persons on sick leave exceeding 8 weeks to job centers, where social workers assess the need for return-to-work support.

In the Central Denmark Region, CR is an essential part of treatment for persons with IHD and is offered after hospital discharge. Persons are referred to CR by a cardiologist after examination and risk assessment. During CR in primary healthcare settings, hospital specialists are responsible for the medical treatment and are available to healthcare providers for consultations and advice (Katballe et al., 2015).

Content of cardiac rehabilitation in primary healthcare settings

The content of CR in the Central Denmark Region was delineated using Template for Intervention Description and Replication (TIDieR) framework through interviews with the 10 CR teams (Hoffmann et al., 2014; Pedersen et al., 2022). Each primary healthcare setting employed a CR team comprising nurses and physiotherapies to deliver the 12-week program, encompassing risk factors assessment and management, supervised exercise training, patient education, and psychosocial counselling (Cowie et al., 2019; Katballe et al., 2015). Supervised exercise training included 24 sessions with focus on aerobic training. In 8 of 10 primary healthcare settings, the exercise training sessions lasted 60 min, and in the two remaining primary healthcare settings, the sessions lasted 70–75 min. Patient education sessions ranged from 6 to 12, with an average of 8 sessions, and addressing social skills, empowerment, and health behavior improvement. Although methods for identifying persons requiring return-to-work support were not explicitly outlined or included in patient education, collaboration with local job centers was emphasized. CR culminated in consultations aimed at developing post-CR coping strategies (Pedersen et al., 2022).

Current study

Study design and study population

This cohort study included persons aged 18 to 65 years, excluding those on disability pension due to their inability to return to work.

Data collection and data sources

Information on demographic, socioeconomic characteristics, and CR participation degree was obtained from the online quality improvement database “Cardiac Rehabilitation in Primary Healthcare Settings” (hereafter database). This database, initiated in 2017 by regional health authorities in the Central Denmark Region, facilitated questionnaire dissemination during the clinical trial period.

Employment status data were retrieved from the Danish Register for Evaluation of Marginalization (DREAM) (Hjollund et al., 2007). The register includes all Danish citizens, who at some point since 1991 have received social benefits (e.g., unemployment benefits, sickness benefits or disability pension). The type of social benefits in DREAM is recorded for each week if the person has received the benefit for at least one day. Termination of registration occurs following the first full week of not receiving any type of social benefit (Hjollund et al., 2007). Employment status was tracked from the date the participant started CR (baseline) until 18 months in the DREAM register.

Exposure

Successful CR completion was defined as attending ≥75% of the program, which has been applied in previous studies (Pedersen et al., 2022; Sunamura et al., 2020). Healthcare providers recorded each participants’ attendance in supervised physical exercise and patient education sessions in the database. The number of attended sessions was divided by the number of offered sessions as recorded in TIDieR in the municipality where the individual was enrolled in CR (Pedersen et al., 2022).

Outcome

Employment status was assessed through two outcomes:

Working at 6- and 18-months’ follow-up.

Number of weeks working during 6- and 18-months’ follow-up.

Working was defined as not receiving any social transfer income, except unemployment benefits (persons who were fit for duty but not currently employed) or flexible job (job for persons with reduced ability to work).

Covariates

Covariates related to CR and employment status were determined based on existing literature (Pedersen et al., 2023; Sadeghi et al., 2022; Salzwedel et al., 2019). Data on sex, age, cohabitation, and educational level were extracted from the database. Comorbidity was defined using the Charles Comorbidity Index, derived from ICD-10 condition in the National Patient Registry up to ten years before index time (defined as referral date to CR) (Thygesen et al., 2011). The questionnaire included several validated instruments. Work Ability Index (WAI), with a score of 1–10, a higher score indicates higher work ability (Ahlstrom et al., 2010). Hospital Anxiety and Depression Scales (HADS) indicates level of symptoms of anxiety (7 items) and depression (7 items), a higher score indicates a higher level of symptoms (Bambauer et al., 2005). Coping skills were defined using Patient Activation Measure (13 items) which indicated knowledge, skills, and confidence for self-management. A high subscale score (scale 1–100) indicated higher patient activation (Hibbard & Tusler, 2007). Health-related quality of life was measured with HeartQol (14 items) with a scale response of 0–3, a higher score indicates higher quality of life (Oldridge et al., 2014). Baseline employment status was obtained from the DREAM register (Hjollund et al., 2007).

Statistical analysis

Descriptive statistics were conducted to delineate baseline characteristics between CR completers and non-completers. Logistic regression was utilized to assess the association between CR completion and employment status at 6- and 18-months’ follow-up, while linear regression was utilized to estimate the association between CR completion and number of working weeks during 6- and 18-month follow-up. Results from both regression models were presented in crude and adjusted format, accounting for sex, age, educational level, comorbidity, work ability, symptoms of depression and anxiety and baseline employment status. Additionally, adjustments were made for cluster-variants among the ten municipalities in the Central Denmark Region. A significance threshold of p < 0.05 was adopted to determine statistical significance. All analyses were conducted using Stata version 17 (StataCorp, 2021) (Table 1).

Table 1.

Baseline characteristics of the study population.

	Total, n = 244		CR Completers, n = 109		CR non-completers,n = 135
Sex, n (%)
Male	197	(80.7)	87	(79.8)	110	(81.5)
Female	47	(19.3)	22	(20.2)	25	(18.5)
Age
Mean (SD)	55.8	(6.4)	56.3	(5.8)	55.4	(6.8)
Cohabitation (n = 241), n (%)
Living alone	54	(22.4)	23	(21.1)	31	(23.5)
Living with partner	187	(77.6)	86	(78.9)	101	(76.5)
Educational level (n = 224), n (%)
None, short courses and other	42	(18.7)	21	(20.2)	21	(17.4)
Skilled worker	89	(39.5)	46	(44.2)	43	(35.5)
Higher education	94	(41.8)	57	(35.6)	57	(47.1)
Comorbidity, n (%)
0	201	(82.4)	92	(84.4)	109	(80.7)
≥1	43	(17.6)	17	(15.6)	26	(19.3)
Work ability (n = 213)
Mean (SD)	4.8	(5.2)	4.8	(5.3)	4.9	(5.1)
Symptoms of depression (n = 212)
Mean (SD)	3.2	(3.6)	2.8	(3.1)	3.5	(3.9)
Symptoms of anxiety (n = 212)
Mean (SD)	4.1	(3.8)	3.9	(3.8)	4.2	(3.8)
Coping skills (n = 212)
Mean (SD)	63.1	(14.1)	62.4	(14.1)	63.8	(14.0)
Health-related Quality of life (n = 212)
Mean (SD)	2.1	(0.6)	2.1	(0.6)	2.2	(0.7)
Employment status, n (%)
Working	108	(44.3)	50	(45.9)	58	(43.0)
Not working	136	(55.7)	59	(54.1)	77	(57.0)

Ethics approval and consent to participate

The clinical trial (Pedersen et al., 2022) received approval by the Danish Data Protection Agency under the Central Denmark Region (ID:1–16-02–84-20) and was registered at ClinicalTrials.gov (ID: NCT03734185). The study adhered to the ethical principles outlined in the Declaration of Helsinki. CR teams informed persons about the project and obtained written informed consent. This study was conducted and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in epidemiology) statement (Cuschieri, 2019).

Results

Study population

Out of 514 persons with IHD who consented to participate, those above 65 years old or receiving disability pension were excluded, resulting in a final study population of 244 participants, comprising 109 completers and 135 non-completers of the CR program (Figure 1).

Figure 1.

Flow diagram of the study population.

Employment status at 6- and 18-months’ follow-up

At 6 months’ follow-up, 65.9% of the study population were working, with 47.8% being CR completers and 52,2% non-completers. Similarly, at 18 months’ follow-up, 69.3% of the participants were working, including 45.0% completers and 55.0% non-completers (Table 2). However, no statistically significant difference in employment status was noted between CR completers and non-completers at both 6- and 18-months’ follow-up (Table 2).

Table 2.

Odds ratio for CR completion and working at 6- and 18-months of follow-up.

	6 months			18 months
	Working	Crude, n = 244	Adjusted^a,bn = 184	Working	Crude, n = 244	Adjusted^a,bn = 184
	n (%)	OR (95% CI)	OR (95% CI)	n (%)	OR (95% CI)	OR (95% CI)
All	161 (65.98)			169 (69.26)
Completers, n = 109	77 (70.64)	1.46 (0.87;2.46)	1.17 (0.55;2.49)	76 (69.72)	1.04 (0.59;1.83)	0.69 (0.27;1.82)
Non-completers, n = 135	84 (62.22)	1.00	1.00	93 (68.89)	1.00	1.00

CR = Cardiac rehabilitation.

OR = Odds ratio; 95% CI = Confidence intervals.

Adjusted for sex, age, educational level, comorbidity, work ability, symptoms of depression and anxiety, and employment status at baseline.

Non-responders; n = 60 (completers n = 23 and non-completers n = 37).

Weeks working during 6 and 18 months’ follow-up

At 6 months, completers had worked an average of 13.9 weeks, while non-completers had worked an average of 13.7 weeks. At 18 months, completers had worked on average for 50.5 weeks, compared to 48.3 weeks for non-completers (Table 3). Notably, there was no statistically significant difference in the number of weeks worked between CR completers and non-completers at both 6 and 18 months’ follow-up (Table 3).

Table 3.

Weeks working during 6- and 18-months follow-up among CR completers and non-completers.

	6 months			18 months
	Weeks working	Crude difference,n = 244	Adjusted difference^a,bn = 184	Weeks working	Crude difference, n = 244	Adjusted difference^a,bn = 184
CR	Mean (SD)	Mean (95% CI)	Mean (95% CI)	Mean (SD)	Mean (95% CI)	Mean (95% CI)
Completers, n = 109	13.89 (11.41)	−0.21 (−2.79;2.36)	−0.87 (−1.24;2.99)	50.53 (27.77)	2.27 (−10.50;5.98)	0.30 (−7.71;8.32)
Non-completers, n = 135	13.68 (10.17)	0.00	0.00	48.27 (31.68)	0.00	0.00

CR = Cardiac rehabilitation.

SD = standard deviation, 95% CI = Confidence Intervals.

Adjusted for Sex, age, level of education, comorbidity, work ability, symptoms of depression and anxiety, and employment status.

Non-responders; n = 60 (completers n = 23 and non-completers n = 37).

Discussion

Our study aimed to investigate the association between completing CR and employment in primary health care settings. Our findings revealed no statistically significant differences in employment status at 6- and 18-months’ follow-up or the number of weeks working during 6- and 18-months’ follow-up between participants who completed ≥ 75% of CR and those who completed <75% of CR.

Overall, our results align previous findings indicating that approximately two-thirds of persons attending CR are employed at the 12-month mark following attendance (Bergvik et al., 2012; Sadeghi et al., 2022). However, it is noteworthy that in one study, despite a significant majority (91.1%) returning to work within one year, a considerable portion (24.2%) were detached from employment and received social benefits one year after their return (Smedegaard et al., 2017). The process of returning to work post-cardiovascular disease is multifaceted, and influenced by individual factors, as well as work-related considerations, components within health and social care systems, and social security policies and regulations (Andersen et al., 2023). Additionally, two-thirds of surveyed patients reported not being offered vocational rehabilitation, while nearly half of those expressing a need for vocational counseling found their needs unmet (Bernt Jørgensen et al., 2022). These challenges could aid in understanding why only two-thirds are employed after 12 months.

It may come as a surprise that the employment rate following CR in primary healthcare settings is not higher compared to hospital rehabilitation, considering the potential for developing personalized return-to-work plans within interdisciplinary teams spanning health and social care sectors, which also involve employers to ensure awareness of relevant work accommodations (Bernt Jørgensen et al., 2023; Olejaz et al., 2012). In our study, this trend may be elucidated by a significant number of patients opting out of CR and choosing to return to work instead, despite employers being legally obligated to provide compensation support. (Bosma et al., 2021). This phenomenon can be attributed to a complex emotional dilemma experienced by persons who must decide whether to forgo CR and return to work for financial stability, or grapple with concerns about managing their responsibilities during their absence at CR and the potential burden placed on their colleagues with increased workload (SS et al., 2018). Starting work before being physically and mentally prepared to handle the tasks could result in disengagement from employment and the subsequent receipt of social benefits one year after their return (Smedegaard et al., 2017).

Our TIDieR description reveals a gap in the integration of return-to-work strategies within CR programs, leading to uncertainty regarding staff support for patients’ return to work in CR. There is a pressing need for a deeper understanding of the requirements and the incorporation of returning to work as a core component of CR team support for patients seeking re-entry into the workforce. Collaborative efforts involving patients, relevant CR team members, and social workers have shown promising outcomes for return-to-work initiatives (Bernt Jørgensen et al., 2023), underscoring the importance of closer cooperation among all stakeholders to enhance these efforts.

Strengths and limitations

We obtained consent from 10 out of 19 primary healthcare settings to participate in the project. However, our inability to access data from non-participating settings limits our insight into potential differences between these settings and the participating ones. Consequently, there is a risk of bias, while questions may arise regarding the absence of validation regarding data quality assessment. (Pedersen et al., 2022). Nonetheless, a notable strength of the study is the utilization of data from a mandatory clinical database. By linking patients’ unique CPR numbers with the nationally validated DREAM database (Hjollund et al., 2007), we mitigated the risk of selection bias.

There is a risk of participation bias, as our study population appears to consist of resourceful persons, evident from their low reported symptoms of depression and anxiety, high scores of coping skills, and high level of health-related quality of life compared to other studies (Pedersen et al., 2023; Salzwedel et al., 2019). This may have affected the external validity of the study, as resourceful persons are more likely to return to work than those with fewer resources (Bernt Jørgensen et al., 2022; Sadeghi et al., 2022), potentially leading to overestimated results.

A more comprehensive description of vocational rehabilitation within CR would have enhanced the study’ value, providing insight into the support provided during the program. While returning to work is a fundamental component of CR, our data lacks specific details on how and when CR teams support patients in this aspect.

Furthermore, a larger patient cohort would have been advantageous, as the small sample size may not adequately detect differences between groups. Additionally, the limited sample size has resulted in few strata, potentially leading to residual confounding and limiting adjustments for additional factors.

Conclusion

The successful completion of CR did not significantly facilitate the return to work for persons with IHD within an 18-months period following the program. However, it is noteworthy that a considerable proportion of both completers and non-completers were employed in the subsequent period after CR. It remains unclear whether CR adheres to recommendations for return to work. Therefore, further research focusing on effective strategies for retaining persons in the workforce would be highly relevant and valuable.

Footnotes

Ethics statement

The clinical trial received approval by the Danish Data Protection Agency under the Central Denmark Region (ID:1–16-02–84-20) and was registered at ClinicalTrials.gov (ID: NCT03734185). The study adhered to the ethical principles outlined in the Declaration of Helsinki. This study was conducted and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in epidemiology) statement (Cuschieri, 2019).

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Informed consent

The participant received written information in advance before accepting to participate in the study followed by oral information which briefly repeated the written materials and opened for discussion.

Acknowledgements

Thanks to all participants and stakeholders.

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