Impact of Health Care System Delay in Patients With ST-Elevation Myocardial Infarction on Return to Labor Market and Work Retirement
2014; Elsevier BV; Volume: 114; Issue: 12 Linguagem: Inglês
10.1016/j.amjcard.2014.09.018
ISSN1879-1913
AutoresKristina Grønborg Laut, Jacob Hjort, Thomas Engstrøm, Lisette Okkels Jensen, Hans-Henrik Tilsted Hansen, Jan Skov Jensen, Frants Pedersen, Erik Jørgensen, Lene Holmvang, Alma B Pedersen, Erika Frischknecht Christensen, Freddy Lippert, T Lang‐Jensen, H Jans, Poul Anders Hansen, Sven Trautner, Steen Dalby Kristensen, Jens Flensted Lassen, Timothy L. Lash, Peter Clemmensen, Christian Juhl Terkelsen,
Tópico(s)Healthcare Policy and Management
ResumoSystem delay (delay from emergency medical service call to reperfusion with primary percutaneous coronary intervention [PPCI]) is acknowledged as a performance measure in ST-elevation myocardial infarction (STEMI), as shorter system delay is associated with lower mortality. It is unknown whether system delay also impacts ability to stay in the labor market. Therefore, the aim of the study was to evaluate whether system delay is associated with duration of absence from work or time to retirement from work among patients with STEMI treated with PPCI. We conducted a population-based cohort study including patients ≤67 years of age who were admitted with STEMI from January 1, 1999, to December 1, 2011 and treated with PPCI. Data were derived from Danish population-based registries. Only patients who were full- or part-time employed before their STEMI admission were included. Association between system delay and time to return to the labor market was analyzed using a competing-risk regression analysis. Association between system delay and time to retirement from work was analyzed using a Cox regression model. A total of 4,061 patients were included. Ninety-three percent returned to the labor market during 4 years of follow-up, and 41% retired during 8 years of follow-up. After adjustment, system delay >120 minutes was associated with reduced resumption of work (subhazard ratio 0.86, 95% confidence interval 0.81 to 0.92) and earlier retirement from work (hazard ratio 1.21, 95% confidence interval 1.08 to 1.36). In conclusion, system delay was associated with reduced work resumption and earlier retirement. This highlights the value of system delay as a performance measure in treating patients with STEMI. System delay (delay from emergency medical service call to reperfusion with primary percutaneous coronary intervention [PPCI]) is acknowledged as a performance measure in ST-elevation myocardial infarction (STEMI), as shorter system delay is associated with lower mortality. It is unknown whether system delay also impacts ability to stay in the labor market. Therefore, the aim of the study was to evaluate whether system delay is associated with duration of absence from work or time to retirement from work among patients with STEMI treated with PPCI. We conducted a population-based cohort study including patients ≤67 years of age who were admitted with STEMI from January 1, 1999, to December 1, 2011 and treated with PPCI. Data were derived from Danish population-based registries. Only patients who were full- or part-time employed before their STEMI admission were included. Association between system delay and time to return to the labor market was analyzed using a competing-risk regression analysis. Association between system delay and time to retirement from work was analyzed using a Cox regression model. A total of 4,061 patients were included. Ninety-three percent returned to the labor market during 4 years of follow-up, and 41% retired during 8 years of follow-up. After adjustment, system delay >120 minutes was associated with reduced resumption of work (subhazard ratio 0.86, 95% confidence interval 0.81 to 0.92) and earlier retirement from work (hazard ratio 1.21, 95% confidence interval 1.08 to 1.36). In conclusion, system delay was associated with reduced work resumption and earlier retirement. This highlights the value of system delay as a performance measure in treating patients with STEMI. There is ample evidence that time from first contact with the health care system to initiation of reperfusion therapy (system delay) is associated with mortality in patients with ST-elevation myocardial infarction (STEMI).1De Luca G. van 't Hof A.W. de Boer M.J. Ottervanger J.P. Hoorntje J.C. Gosselink A.T. Dambrink J.H. Zijlstra F. Suryapranata H. Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty.Eur Heart J. 2004; 25: 1009-1013Crossref PubMed Scopus (197) Google Scholar, 2Steg P.G. James S.K. Atar D. Badano L.P. Lundqvist C.B. Borger M.A. Di Mario C. Dickstein K. Ducrocq G. Fernandez-Aviles F. Gershlick A.H. Giannuzzi P. Halvorsen S. Huber K. Juni P. Kastrati A. Knuuti J. Lenzen M.J. Mahaffey K.W. Valgimigli M. Van't Hof A. Widimsky P. Zahger D. Bax J.J. Baumgartner H. Ceconi C. Dean V. Deaton C. Fagard R. Funck-Brentano C. Hasdai D. Hoes A. Kirchhof P. Kolh P. McDonagh T. Moulin C. Popescu B.A. Reiner Z. Sechtem U. Sirnes P.A. Tendera M. Torbicki A. Vahanian A. Windecker S. Astin F. Astrom-Olsson K. Budaj A. Clemmensen P. Collet J.P. Fox K.A. Fuat A. Gustiene O. Hamm C.W. Kala P. Lancellotti P. Maggioni A.P. Merkely B. Neumann F.J. Piepoli M.F. Van de Werf F. Verheugt F. Wallentin L. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation.Eur Heart J. 2012; 33: 2569-2619Crossref PubMed Scopus (150) Google Scholar, 3Terkelsen C.J. Sorensen J.T. Maeng M. Jensen L.O. Tilsted H.H. Trautner S. Vach W. Johnsen S.P. Thuesen L. Lassen J.F. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention.JAMA. 2010; 304: 763-771Crossref PubMed Scopus (518) Google Scholar Approximately 45% of all patients admitted with acute myocardial infarction (AMI) are of the working age.4Network E.H. European Cardiovascular Disease Statistics. Report.2012Google Scholar, 5Schmidt M. Jacobsen J.B. Lash T.L. Botker H.E. Sorensen H.T. 25 year trends in first time hospitalisation for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study.BMJ. 2012; 344: e356Crossref PubMed Scopus (371) Google Scholar In 2009, loss in production because of cardiovascular heart disease mortality and morbidity was estimated to cost the European Union around €18 billion, of which about 9% is due to illness among patients of working age.6Leal J, Luengo-Fernandez R, Gray A. Economic costs. In: Nichols M, Townsend N, Scarborough P, Rayner M. European Cardiovascular Disease Statistics 2012. Brussels: European Heart Network, European Society of Cardiology, Sophia Antipolis 1–129.Google Scholar Only few studies have evaluated return-to-work rates and retirement in patients with STEMI treated with primary percutaneous coronary intervention (PPCI), and these have been based on small study samples.7Isaaz K. Coudrot M. Sabry M.H. Cerisier A. Lamaud M. Robin C. Richard L. Da Costa A. Khamis H. Abd-Alaziz A. Gerenton C. Return to work after acute ST-segment elevation myocardial infarction in the modern era of reperfusion by direct percutaneous coronary intervention.Arch Cardiovasc Dis. 2010; 103: 310-316Crossref PubMed Scopus (33) Google Scholar, 8Abbas A.E. Brodie B. Stone G. Cox D. Berman A. Brewington S. Dixon S. O'Neill W.W. Grines C.L. Frequency of returning to work one and six months following percutaneous coronary intervention for acute myocardial infarction.Am J Cardiol. 2004; 94: 1403-1405Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Shorter system delay is associated with lower risk of development of congestive heart failure after STEMI.9Terkelsen C.J. Jensen L.O. Tilsted H.H. Trautner S. Johnsen S.P. Vach W. Botker H.E. Thuesen L. Lassen J.F. Health care system delay and heart failure in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: follow-up of population-based medical registry data.Ann Intern Med. 2011; 155: 361-367Crossref PubMed Scopus (76) Google Scholar Work outcome likely depends on left ventricular function (left ventricular ejection fraction), but it has not been evaluated whether shorter system delay affects the probability of return to the labor market or retirement from work. The aim of the present nationwide study was to examine the association between system delay and time to work resumption and time to retirement from work in patients with STEMI treated with PPCI. We conducted a population-based historical cohort study including all patients ≤67 years who were admitted with STEMI from January 1, 1999, to December 1, 2011. Only patients who were full-time or part-time employed, 3 weeks before STEMI were included, and for each patient only the first admission with STEMI during the study period was included. Eligible patients were transported by the emergency medical services (EMS), treated with PPCI within 12 hours of symptom onset at 1 of the 5 PCI-centers in Denmark (Aalborg, Gentofte, Odense, Rigshospitalet, and Aarhus University Hospital in Skejby), and had a maximal system delay of 360 minutes (Figure 1). Patients with STEMI were identified from the Western Denmark Heart Registry (West Denmark) and the invasive cardiology (PATS) databases at Gentofte and Rigshospitalet (Eastern Denmark). These registries collect baseline characteristics and patient- and procedure-specific information on all angiographies and coronary interventions performed in all adult patients in Denmark since 1999. In 2008 the registration was 98% complete for PPCI.10Schmidt M. Maeng M. Jakobsen C.J. Madsen M. Thuesen L. Nielsen P.H. Botker H.E. Sorensen H.T. Existing data sources for clinical epidemiology: The Western Denmark Heart Registry.Clin Epidemiol. 2010; 2: 137-144Crossref PubMed Google Scholar The Danish health care system provides universal tax-supported healthcare, guaranteeing free access to general practitioners and hospitals, including EMS transportation for all inhabitants (5.5 million). The civil registration number, a 10-digit unique personal identifier number is assigned to all Danish residents at birth or immigration and used in all Danish healthcare registries,11Pedersen C.B. The Danish Civil Registration System.Scand J Public Health. 2011; 39: 22-25Crossref PubMed Scopus (3067) Google Scholar enabling unambiguous linkage on individual level of data from Western Denmark Heart Registry and PATS databases and other Danish registries. The study was registered and approved by the Danish Data Protection Agency (J # 2012-41-0043), the Danish Health and Medicines Authority (j.nr.3-3013-81/1), and the National Board of Health (J.nr. 6-8011-978/1). System delay was defined as the time from first contact to the EMS (112 call) to first catheterization with a guiding catheter during PPCI.3Terkelsen C.J. Sorensen J.T. Maeng M. Jensen L.O. Tilsted H.H. Trautner S. Vach W. Johnsen S.P. Thuesen L. Lassen J.F. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention.JAMA. 2010; 304: 763-771Crossref PubMed Scopus (518) Google Scholar, 12Lassen J.F. Botker H.E. Terkelsen C.J. Timely and optimal treatment of patients with STEMI.Nat Rev Cardiol. 2013; 10: 41-48Crossref PubMed Scopus (45) Google Scholar The Danish EMS system including time registration has been described in detail elsewhere.3Terkelsen C.J. Sorensen J.T. Maeng M. Jensen L.O. Tilsted H.H. Trautner S. Vach W. Johnsen S.P. Thuesen L. Lassen J.F. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention.JAMA. 2010; 304: 763-771Crossref PubMed Scopus (518) Google Scholar First catheterization with a guiding catheter during PPCI was derived from the Western Denmark Heart Registry and PATS. System delay was categorized into 2 groups, namely ≤120 minutes and >120 minutes. Outcomes were time to return to labor market, time to work retirement, and length of sick-leave period. All data were derived from the Danish National Register on Public Transfer Payments (DREAM). DREAM was founded in 1991 and includes weekly registration on public transfer payments from any Danish authority given to all persons with a civil registration number.13Hjollund N.H. Larsen F.B. Andersen J.H. Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a population-based survey.Scand J Public Health. 2007; 35: 497-502Crossref PubMed Scopus (340) Google Scholar DREAM is maintained by the Danish Ministry of Employment and updated monthly. By 2012, about 5 million Danes were registered. Those not included should not have received any transfer income from any Danish authority during the last 20 years.13Hjollund N.H. Larsen F.B. Andersen J.H. Register-based follow-up of social benefits and other transfer payments: accuracy and degree of completeness in a Danish interdepartmental administrative database compared with a population-based survey.Scand J Public Health. 2007; 35: 497-502Crossref PubMed Scopus (340) Google Scholar Each patient's work situation was evaluated 1 year before and up to 8 years after the index PPCI procedure. We recoded the original 104 different transfer-payment codes into 4 variables, namely (1) employment, (2) retirement from work, (3) sick leave, and (4) death (Supplementary Table 1). Work resumption was defined as return to full- or part-time work and required 4 full consecutive weeks with no registration in the DREAM database or 1 of the transfer-payment codes predefined as "employment" (Supplementary Table 1). Retirement included the following 3 categories: (1) persons who were granted disability pension, available for those aged 18 to 59; (2) voluntary early retirement pension, available for those aged 60 to 65; and (3) public retirement pension, available for those aged 65+. In Denmark, the general retirement age is 65 to 67 years for both genders depending on birth year, but in the private sector and some occupations a higher retirement age is applicable. Sick leave was defined as 1 or more full weeks on sickness allowance. In Denmark, sick leave extending beyond 3 weeks must be sanctioned by the workers' general practitioner. Workers are entitled to receive sickness allowance for a maximum period of 52 weeks within an 18 month period with full compensation. We used the Danish National Registry of Patients to identify co-morbid conditions before STEMI. This registry holds records of all nonpsychiatric hospitalizations in Denmark since 1977 and outpatient visits since 1995, including the dates of admission and discharge, and up to 20 discharge diagnoses classified according to International Classification of Diseases (eighth edition until the end of 1993 and tenth edition thereafter).14Andersen T.F. Madsen M. Jorgensen J. Mellemkjoer L. Olsen J.H. The Danish National Hospital Register. A valuable source of data for modern health sciences.Dan Med Bull. 1999; 46: 263-268PubMed Google Scholar Based on the complete hospitalization history of each patient, we computed the Charlson Co-morbidity Index. We classified co-morbidity into 2 categories, namely no co-morbidity and 1 or more co-morbidities.15O'Connell R.L. Lim L.L. Utility of the Charlson comorbidity index computed from routinely collected hospital discharge diagnosis codes.Methods Inf Med. 2000; 39: 7-11PubMed Google Scholar We obtained information on vital status until July 19, 2012, from the Danish Civil Registration System. This registry contains information on all Danish residents from 1968 onward and includes daily updated information on vital status and migration.11Pedersen C.B. The Danish Civil Registration System.Scand J Public Health. 2011; 39: 22-25Crossref PubMed Scopus (3067) Google Scholar Follow-up ended on July 19, 2012, and median follow-up time was 239 weeks (interquartile range [IQR] 126 to 358 weeks). When looking at return to labor market, follow-up began on the day of PPCI and ended on the date of return to the labor market, work retirement, death, emigration, or after 208 weeks of follow-up (4 years, this to ensure that at least 10% of the study population remained at risk), whichever came first. When looking at work retirement, follow-up began on the day of PPCI and ended at the date of work retirement, death, emigration, or after 416 weeks of follow-up (8 years, this to ensure at least 10% of the study population remained at risk), whichever came first. Continuous data are summarized as medians with IQR. Categorical variables are reported as frequencies and percentages. The chi-square test and Wilcoxon rank sum test were used for comparisons of categorical variables and continuous variables as appropriate. Missing values among covariates were replaced with their conditional means, obtained from multiple imputations by the Stata ICE (StataCorp, College Station, Texas) command.16White I.R. Royston P. Wood A.M. Multiple imputation using chained equations: Issues and guidance for practice.Stat Med. 2011; 30: 377-399Crossref PubMed Scopus (5546) Google Scholar We imputed 10 data sets based on the covariates listed in Table 1. However, Killip class and predisposition of ischemic heart disease were missing in >20% of patients, so we chose not to impute them, and these variables were therefore not included in the final analysis.Table 1Characteristics of patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention and working three weeks before STEMI, stratified according to system delay (N=4,061)CharacteristicsSystem delay (minutes)∗System delay is the time from first contact with the 112 service system until Primary Percutaneous Coronary Intervention.P Value≤120 (N 2,305)∗System delay is the time from first contact with the 112 service system until Primary Percutaneous Coronary Intervention.>120 (N 1,756)∗System delay is the time from first contact with the 112 service system until Primary Percutaneous Coronary Intervention.Patients (%)Valid CasesPatients (%)Valid CasesMedian system delay (IQR†IQR = Interquartile range.) (minutes)89.3 (73.3-104.5)2,305157.9 (135.9-192.7)1,756<0.001Median age (IQR†IQR = Interquartile range.) (years)54 (48-59)2,30555(49-59)1,7560.04Women334 (15%)2,305291 (17%)1,7560.07Non-married626 (27%)2,305418 (24%)1,7560.02Comorbidity 01,913 (83%)2,3051,446 (82%)1,7560.59 1+392 (17%)310 (18%)Treated hypertension520 (24%)2,173357 (22%)1,6250.15Diabetes mellitus139 (6%)2,18687 (5%)1,6410.18Familiar disposition IHD‡Ischemic Heart Disease.730 (46%)1,586606 (43%)1,3930.17Active or previous smoker1,832 (89%)2,0561,273 (85%)1,4890.001Killip class1,6601,5050.09I1,572 (95%)1,404 (93%)II-IV88 (5%)101 (7%)Median duration (IQR†IQR = Interquartile range.) (weeks) of work absenteeism during 4-years of follow-up10 (0-27)2,30512 (3-31)1,756<0.01∗ System delay is the time from first contact with the 112 service system until Primary Percutaneous Coronary Intervention.† IQR = Interquartile range.‡ Ischemic Heart Disease. Open table in a new tab We performed 2 different types of analyses. (1) The 4-year probability of returning to the labor market was assessed by the cumulative incidence function with death and work retirement as competing risks.17Putter H. Fiocco M. Geskus R.B. Tutorial in biostatistics: competing risks and multi-state models.Stat Med. 2007; 26: 2389-2430Crossref PubMed Scopus (1596) Google Scholar Cumulative incidence curves were stratified according to intervals of system delay. Associations between system delay, selected clinical and demographic data, and work resumption were assessed using multivariate competing-risk analysis estimating subhazard ratios with 95% confidence intervals. (2) We used Cox proportional hazards regression to compute adjusted incidence rates (hazard ratios) of work retirement during an 8-year period with 95% confidence interval. Cumulative incidences were stratified according to intervals of system delay with death as a competing risk. Comparisons of groups were performed by including system delay as a categorical variable in both the competing risk analysis and the Cox proportional hazards regression. We included year of index PPCI in the multivariate models to reveal a possible time trend. In the Cox regression analysis, the assumption of proportional hazards was assessed graphically and found appropriate. In the competing-risk regression analyses, the proportional hazards assumption was checked by evaluating whether the subhazard ratios for each covariate were time-varying. A p value <0.05 was considered to indicate statistical significance. All statistical analyses were carried out using Stata 11.0 statistical software (StataCorp, College Station, Texas). Our final analytic sample included 4,061 patients with STEMI treated with PPCI and with a treatment delay of 120 minutes, patients with system delays of ≤120 minutes were more likely to be younger, not married, and active smokers (Table 1). There were no differences between groups regarding co-morbidity and gender (Table 1). At 1 month, 29% (n = 673) of patients with a system delay of ≤120 minutes had returned to the labor market, 96% of whom to a full-time position (Figure 2). In patients with a system delay of >120 minutes, 25% had returned to work at 1 month (n = 436) with 94% being employed full-time. At 1 year the proportion of patients being employed had increased to 87% (n = 2,017) and 83% (n = 1,456) in the 2 groups, respectively. During follow-up, 93% (n = 2,137) of patients with a system delay of ≤120 minutes had returned to the labor market, whereas this was true for 89% (n = 1,557) of patients with a system delay of >120 minutes (Figure 2). Table 2 lists factors associated with return to the labor market. In this multivariate analysis, system delay of >120 minutes remained associated with a lower chance of returning to the labor market. Moreover, men had a lower chance of returning to work compared with women. The association between system delay and return to work did not change over years.Table 2Multivariable analyses of covariates associated with return to the labor market, and retirement from work after ST-elevation myocardial infarction in patients treated with primary percutaneous coronary intervention (PPCI) (N: 4,061)Covariates included in the modelsReturn to labor market (SHR)∗Return to labor market–Analysis based on competing-risk analysis with death and work retirement as competing risks. SHR = Sub Hazard Ratios. Variables are mutual adjusted. (95% CI)(N= 4,061)P-valueRetirement from work(HR)†Work retirement–Analysis based on cox-regression modeling. HR = Hazard Ratios. Variables are mutual adjusted. (95% CI)(N= 4,061)P-valueSystem delay >120 minutes‡System delay is the time from first contact with the 112 service system until PPCI.0.86 (0.81, 0.92)<0.0011.21 (1.08, 1.36)0.001Age (Years) <501.00 Reference<0.051.00 Reference<0.001 50-<600.93 (0.88, 1.00)5.10 (4.05, 6.42) 60+0.91 (0.82, 1.00)31.11 (24.51, 39.50)Men0.82 (0.76, 0.89)<0.0011.17 (1.00, 1.36)0.05Married1.00 Reference0.421.00 Reference 20060.94 (0.89, 1.00)0.95 (0.83, 1.09)∗ Return to labor market–Analysis based on competing-risk analysis with death and work retirement as competing risks. SHR = Sub Hazard Ratios. Variables are mutual adjusted.† Work retirement–Analysis based on cox-regression modeling. HR = Hazard Ratios. Variables are mutual adjusted.‡ System delay is the time from first contact with the 112 service system until PPCI. Open table in a new tab A total of 29% (n = 1,192) of the study population retired during follow-up. Proportions of people retired at 1 year were 6.6% (n = 152) in the group of patients with a system delay of ≤120 minutes compared with 8.6% (n = 151) in the group with a system delay of >120 minutes (Figure 3). At the end of follow-up, 26% (n = 598) of patients with a system delay of ≤120 minutes had retired compared with 34% (n = 594) of patients with a system delay of >120 minutes. After adjustment for confounding factors, system delay was associated with work retirement (Table 2). The association between system delay and retirement did not change over years (Table 2). A subgroup analysis including only patients 120 minutes. Mean duration of work absenteeism during 4 years of follow-up was 10 weeks (IQR 0 to 27) in patients with system delay of ≤120 minutes and 12 weeks (IQR 3 to 31) in patients with system delay of >120 minutes (p 120 minutes, having an AMI returned to the labor market after a brief period of convalescence. Previous studies report that 50% to 90% of men and women who are working before AMI return to work after the acute event.7Isaaz K. Coudrot M. Sabry M.H. Cerisier A. Lamaud M. Robin C. Richard L. Da Costa A. Khamis H. Abd-Alaziz A. Gerenton C. Return to work after acute ST-segment elevation myocardial infarction in the modern era of reperfusion by direct percutaneous coronary intervention.Arch Cardiovasc Dis. 2010; 103: 310-316Crossref PubMed Scopus (33) Google Scholar, 8Abbas A.E. Brodie B. Stone G. Cox D. Berman A. Brewington S. Dixon S. O'Neill W.W. Grines C.L. Frequency of returning to work one and six months following percutaneous coronary intervention for acute myocardial infarction.Am J Cardiol. 2004; 94: 1403-1405Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 18Hamalainen H. Maki J. Virta L. Keskimaki I. Mahonen M. Moltchanov V. Salomaa V. Return to work after first myocardial infarction in 1991-1996 in Finland.Eur J Public Health. 2004; 14: 350-353Crossref PubMed Scopus (46) Google Scholar, 19Nielsen F.E. Sorensen H.T. Skagen K. A prospective study found impaired left ventricular function predicted job retirement after acute myocardial infarction.J Clin Epidemiol. 2004; 57: 837-842Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 20Boudrez H. De Backer G. Recent findings on return to work after an acute myocardial infarction or coronary artery bypass grafting.Acta Cardiol. 2000; 55: 341-349Crossref PubMed Scopus (81) Google Scholar, 21Smith Jr., G.R. O'Rourke D.F. Return to work after a first myocardial infarction. A test of multiple hypotheses.JAMA. 1988; 259: 1673-1677Crossref PubMed Scopus (74) Google Scholar Potential explanations for the high proportion returning to the labor market in our study could be the greater degree of accessibility and follow-up of labor market data through the DREAM database, that our study population was fairly young and with few co-morbid conditions (Table 1) and that we included only patients treated with PPCI, which is regarded as the optimal reperfusion treatment. Adjusting for confounding factors, we found that men had reduced probability of returning to the labor market, which is in contrast to 2 previous studies.7Isaaz K. Coudrot M. Sabry M.H. Cerisier A. Lamaud M. Robin C. Richard L. Da Costa A. Khamis H. Abd-Alaziz A. Gerenton C. Return to work after acute ST-segment elevation myocardial infarction in the modern era of reperfusion by direct percutaneous coronary intervention.Arch Cardiovasc Dis. 2010; 103: 310-316Crossref PubMed Scopus (33) Google Scholar, 19Nielsen F.E. Sorensen H.T. Skagen K. A prospective study found impaired left ventricular function predicted job retirement after acute myocardial infarction.J Clin Epidemiol. 2004; 57: 837-842Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar These conflicting results merit further research, because recent studies indicate that long-term prognosis after PPCI is comparable in men and women.22Jakobsen L. Niemann T. Thorsgaard N. Nielsen T.T. Thuesen L. Lassen J.F. Jensen L.O. Thayssen P. Ravkilde J. Tilsted H.H. Mehnert F. Johnsen S.P. Sex- and age-related differences in clinical outcome after primary percutaneous coronary intervention.EuroIntervention. 2012; 8: 904-911Crossref PubMed Scopus (32) Google Scholar One explanation could be that these previous studies are based on other geographically selected populations, include only small numbers of women, and have been partly based on interview data, which is subject to recall bias. Moreover, it could be speculated that job demands among men are on average more physically challenging than those of women. Although a substantial proportion of our study population returned to the labor market, system delays of >120 minutes was still associated with faster withdrawal from the labor market. In addition, patients with coronary heart disease are known to have impaired health-related quality of life compared with the general population.23Smedt D.D. Clays E. Annemans L. Boudrez H. Sutter J.D. Doyle F. Jennings C. Kotseva K. Pajak A. Pardaens S. Prugger C. Wood D. Bacquer D.D. The association between self-reported lifestyle changes and health-related quality of life in coronary patients: the EUROASPIRE III survey.Eur J Prev Cardiol. 2013 Jan 10; 21 ([Epub ahead of print]): 796-805Crossref PubMed Scopus (27) Google Scholar Recent studies have shown a significant influence of health-related quality of life on long-term outcomes.23Smedt D.D. Clays E. Annemans L. Boudrez H. Sutter J.D. Doyle F. Jennings C. Kotseva K. Pajak A. Pardaens S. Prugger C. Wood D. Bacquer D.D. The association between self-reported lifestyle changes and health-related quality of life in coronary patients: the EUROASPIRE III survey.Eur J Prev Cardiol. 2013 Jan 10; 21 ([Epub ahead of print]): 796-805Crossref PubMed Scopus (27) Google Scholar, 24Spertus J.A. Jones P. McDonell M. Fan V. Fihn S.D. Health status predicts long-term outcome in outpatients with coronary disease.Circulation. 2002; 106: 43-49Crossref PubMed Scopus (402) Google Scholar, 25Xie J. Wu E.Q. Zheng Z.J. Sullivan P.W. Zhan L. Labarthe D.R. Patient-reported health status in coronary heart disease in the United States: age, sex, racial, and ethnic differences.Circulation. 2008; 118: 491-497Crossref PubMed Scopus (126) Google Scholar Despite advances in treatment, many patients still have impaired physical, social, and emotional performance that could result in reduced job retention. Further studies within the area are needed. Health care costs are increasing and retaining people in the labor market is as important as ever. Our study indicates that investing in infrastructure and systems to optimize STEMI strategies—including prehospital diagnosis of STEMI and field triage to reduce delays—may lead, on the long term, to cost savings. The Danish tax-supported health care system and great number of highly reliable registries provide an optimal setting to conduct population-based studies. Still, as in any study design, there is a risk of bias. We were unable to control for several potential confounding factors, such as depression, left ventricular ejection fraction, infarct location, health-related quality of life, educational status, previous category of work, and socio-economic status documented to affect work retention and resumption.7Isaaz K. Coudrot M. Sabry M.H. Cerisier A. Lamaud M. Robin C. Richard L. Da Costa A. Khamis H. Abd-Alaziz A. Gerenton C. Return to work after acute ST-segment elevation myocardial infarction in the modern era of reperfusion by direct percutaneous coronary intervention.Arch Cardiovasc Dis. 2010; 103: 310-316Crossref PubMed Scopus (33) Google Scholar, 26McBurney C.R. Eagle K.A. Kline-Rogers E.M. Cooper J.V. Smith D.E. Erickson S.R. Work-related outcomes after a myocardial infarction.Pharmacotherapy. 2004; 24: 1515-1523Crossref PubMed Scopus (23) Google Scholar, 27O'Neil A. Sanderson K. Oldenburg B. Depression as a predictor of work resumption following myocardial infarction (MI): a review of recent research evidence.Health Qual Life Outcomes. 2010; 8: 95Crossref PubMed Scopus (58) Google Scholar, 28Perk J. Alexanderson K. Swedish Council on Technology Assessment in Health Care (SBU). Chapter 8. Sick leave due to coronary artery disease or stroke.Scand J Public Health. 2004; 32: 181-206Crossref Scopus (44) Google Scholar, 29Meillier L.K. Nielsen K.M. Larsen F.B. Larsen M.L. Socially differentiated cardiac rehabilitation: can we improve referral, attendance and adherence among patients with first myocardial infarction?.Scand J Public Health. 2012; 40: 286-293Crossref PubMed Scopus (37) Google Scholar We do not, however, believe that these factors have a great influence on system delay in our health care setting with equal access to treatment including free EMS transportation. Moreover, the degree of coronary artery disease (number of diseased vessels) and Killip class were missing in up to 38% of the study population. Both variables have shown to be associated with long-term risk for readmission or outpatient contact because of congestive heart failure9Terkelsen C.J. Jensen L.O. Tilsted H.H. Trautner S. Johnsen S.P. Vach W. Botker H.E. Thuesen L. Lassen J.F. Health care system delay and heart failure in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention: follow-up of population-based medical registry data.Ann Intern Med. 2011; 155: 361-367Crossref PubMed Scopus (76) Google Scholar; but again, there is no reason to believe that these factors affected system delay, and thus no reason to believe that they affected the overall findings of the study. Furthermore, data were collected prospectively before we decided to perform the study, thus reducing the risk of information bias. However, sick listing of <3 weeks are not recoded in the DREAM database. In this period, no income is transferred to employers, unless the employee has a chronic disease, in which case the municipal authorities pay the expenses from the very first day. Thus, we were unable to register very short periods of sick leave for all patients. We restricted our study to patients with STEMI in the labor market 3 weeks before the STEMI and to people of working age, which included only 30% of the original source population. This restriction might hamper generalizability of the results to the larger population of all patients with STEMI. The authors have no conflict of interests to disclose. Download .docx (.07 MB) Help with docx files Supplementary Table 1
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