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Department of Cardiology, Herlev and Gentofte University Hospital, Hellerup, DenmarkDepartment of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
Department of Clinical Medicine, University of Copenhagen, Copenhagen, DenmarkDepartment of Cardiology, Rigshospitalet, Copenhagen University hospital, Copenhagen, Denmark
Department of Cardiology, Odense University Hospital, Odense DenmarkDepartment of Clinical Research, University of Southern Denmark, Odense, DenmarkDepartment of Cardiac, Thoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
Knowledge on returning to everyday life after out-of-hospital cardiac arrest (OHCA) is lacking.
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One-fifth of the OHCA-survivors at a working-age was still on paid sick leave after 12 months.
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Increasing age was associated with not returning to the workforce at 3 and 12 months post-OHCA.
Abstract
Background
With increasing survival rates following out-of-hospital cardiac arrest (OHCA), knowledge on return to everyday life, including return to work, should be getting increasing attention.
Objectives
To i) describe patterns of labor market affiliation up to 12 months after discharge among a workforce population and to, ii) investigate the association between clinical and sociodemographic characteristics, self-reported health at discharge and a composite endpoint of prolonged sick leave and leaving the workforce after 3 and 12 months.
Methods
Data from the national survey, DenHeart, were used, including measures of self-reported health: HeartQoL and the Hospital Anxiety and Depression Scale (HADS), combined with register-based follow-up.
Results
During the study period, n = 572 OHCA patients were discharged from five Heart centres, n = 184 were part of the workforce. At discharge, 60% were on paid sick leave, and 20% at 12 months. Age (per one year older) increased the odds of experiencing the composite endpoint at 3 and 12 months (3 months: OR 1.06 95%CI 1.03–1.10, 12 months: OR 1.06 95%CI 1.03–1.09) among the total population (n = 184). Self-reported health at discharge was not associated with the endpoint.
Conclusion
One-fifth of the OHCA survivors at a working-age prior to the OHCA was still on paid sick leave after 12 months. Increasing age was the only characteristic associated with a composite endpoint of prolonged sick leave or leaving the workforce at 3 and 12 months after discharge.
With increasing survival rates, healthcare professionals need to support the population in resuming daily life, including returning to the workforce, when relevant.
As survival rates following out-of-hospital cardiac arrest (OHCA) have improved to an average of 8% across Europe and 16% in Denmark (30-days), the clinical pathway and post-arrest outcomes have gained increasing attention.
Causes of not returning to work can be related to the sequelae of cardiac arrest, as the survivors might suffer from e.g. cognitive impairment and fatigue.
In general, mental health issues seem to be worse among OHCA survivors compared to a general population, particularly among the younger patients (below the age of 65 years).
This highlights how returning to work following OHCA might be challenging for the survivor.
To support the OHCA survivor in returning to the workforce, gaining insight into factors associated with returning – or not returning – to the workforce is essential. These factors might lead to an awareness of focus areas and thus, help clinicians improve the patient pathway following OHCA.
It has previously been demonstrated how older age (compared to being younger), cognitive impairment, fatigue, low educational level and being part-time employed prior to the cardiac arrest were associated with not returning to work.
In general, though, the topic is sparsely investigated, indicating the need for more knowledge to support the OHCA survivor resuming everyday life and returning to work.
Thus, in a workforce population of OHCA survivors, the objectives were to i) describe patterns of labor market affiliation up to 12 months after discharge and to ii) investigate the association between clinical and sociodemographic characteristics, self-reported health at discharge and a composite endpoint of prolonged sick leave and leaving the workforce at 3 and 12 months (short- and long-term after discharge).
Methods
Study design
The current study is based on data from the national DenHeart study, a study based on patient-reported outcomes measured at hospital discharge combined with 1-year register-based follow-up. The design of the overall DenHeart study is described in detail in a previously published study protocol
Patient-reported outcomes at hospital discharge from Heart Centres, a national cross-sectional survey with a register-based follow-up: the DenHeart study protocol.
All patients were consecutively included at hospital discharge from all five Danish Hearts centres between April 2013 and April 2014. The patients were requested to participate in the survey before leaving the hospital. Patients transferred to another hospital were encouraged to complete the survey at the final hospital discharge. Patients either completed and returned the paper-based survey at discharge or by postal mail within three days after discharge.
In the current sub-study, patients diagnosed with cardiac arrest were included. The classification of diagnoses was based on international codes from the ICD-10 list (International Statistical Classification of Diseases and Related Health Problems)
Excluded were: Patients below the age of 18 years and above 63 years, patients without a Danish civil registration number and patients who did not understand Danish. The age limit of 63 was set to ensure a realistic possibility of returning to the workforce following the cardiac arrest (with retirement age, state pension age, of 65 years at the study time). In addition, patients who were unconscious when transferred to another hospital or too ill to participate were also excluded.
Data sources
Clinical and sociodemographic data
Clinical and sociodemographic data were obtained from the following national registers: The Danish National Patient Register (NPR),
The following variables were included: sex, age, marital status (married or not), educational level (basic/primary school, upper secondary/vocational school, higher education), primary diagnosis (based on ICD-10 codes) and co-morbidity (hypertension, ventricular arrhythmia, ischemic heart disease, myocardial infarction, heart failure, renal disease, diabetes, chronic obstructive pulmonary disease, percutaneous cardiac intervention, PCI and coronary artery bypass grafting, CABG). Data on co-morbidity were obtained ten years back from the register, NPR (not including co-morbidity during the index admission). By going back ten years in the registries, we ensured a high coverage of co-morbidities. The number of co-morbidities was used to calculate the overall co-morbidity burden, based on the included co-morbidities in the Ontario Acute Myocardial Infarction Mortality Prediction Rules by Tu et al.
Data on sick leave and absence from the labor market were obtained from the Danish DREAM registry, administrated by the Danish Agency for Labour Market and Recruitment.
Validation of sick leave measures: self-reported sick leave and sickness benefit data from a Danish national register compared to multiple workplace-registered sick leave spells in a Danish municipality.
The DREAM registry data provide information on the public financial benefits of all citizens who have received public transfer payments. The registry contains more than 100 codes available on public benefits reported in weekly inventories.
Validation of sick leave measures: self-reported sick leave and sickness benefit data from a Danish national register compared to multiple workplace-registered sick leave spells in a Danish municipality.
Only sick leave lasting longer than two weeks are included in the DREAM registry. Thus, data on short-term sick leave (below two weeks) are not registered.
Validation of sick leave measures: self-reported sick leave and sickness benefit data from a Danish national register compared to multiple workplace-registered sick leave spells in a Danish municipality.
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.
Return to work indicates that the patient is, in reality, working again. In contrast, return to the workforce is used when the patient is available for the workforce (and not on sick leave).
The current study population was matched to the DREAM registry based on a unique Danish civil registration number, ensuring data on each patient could be matched to possible sick leave benefits. Based on the coding from DREAM, variables were grouped based on the patient's workforce attachment and divided into Sick leave, Working/part of the workforce or Left of the workforce.
The patients included in the group of working/part of the workforce were either employed or unemployed (but still able to work based on the coding in DREAM) or received paid leave or educational grants. Patients who had left the labor market due to early retirement or other reasons or did not have a permanent address in Denmark (immigration) were not considered part of the workforce.
Self-reported health at discharge
Self-reported health, including HRQoL, symptoms of anxiety and depression, were measured with the following patient-reported outcomes measurements at discharge: HeartQol
Also, four ancillary questions regarding height and weight (to calculate body mass index, BMI), smoking status (“current daily smoker”) and alcohol consumption were included. Alcohol consumption was grouped as intake above the national high-risk limit at the time of inclusion (above 14 units/week for women and 21 units/week for men).
HeartQoL is a 14-item, disease-specific questionnaire measuring HRQoL in cardiac patients.
The HeartQoL has a four-weeks recall, and the answers can be summarized into an overall Global, a Physical and an Emotional Score. The scores range from 0 to 3, with higher scores indicating a better HRQoL status. A Cronbach alpha of 0.92 (Global Score), 0.87 (Physical Score) and 0.91 (Emotional Score) have previously been demonstrated in patients with stable coronary artery disease.
Validity and reliability of the HeartQoL questionnaire in a large sample of stable coronary patients: the EUROASPIRE IV Study of the European Society of Cardiology.
The continuous scores of HeartQoL are used in the analyses.
HADS is a disease-specific/domain-specific questionnaire measuring symptoms of anxiety and depression. This instrument consists of 14-items, divided into two subscales; an anxiety scale (HADS-A) and a depression scale (HADS-D). The scales range from 0 to 21, with a cut-off score ≥8 indicating the presence of anxiety (HADS-A ≥ 8) or depression (HADS-D ≥ 8). The internal consistency of HADS has previously been reported with a Cronbach's alpha of 0.87 (HADS-A) and 0.82 (HADS-D) in a Danish population of cardiac patients.
Both continuous scores and the cut-off are used in the analyses.
Outcomes
In the current study, the main endpoints (the events) were a composite of prolonged sick leave or leaving the workforce at 3 and 12 months after discharge, respectively. The composite endpoint was chosen to investigate how clinical and sociodemographic characteristics, HRQoL and symptoms of anxiety and depression at discharge might affect the combined elements – from a short- and long-term perspective following discharge. Prolonged sick leave was defined as a sick leave period of more than the average (6 weeks, standard deviation, SD 5.58 at 3 months and 18 weeks (SD 20.01) at 12 months). To avoid a potential competing risk to the composite endpoint and thus, returning to the workforce, the analyses were only performed on patients alive at 1-year follow-up.
Sample size
The sample size was determined based on the main DenHeart study population.
Patient-reported outcomes at hospital discharge from Heart Centres, a national cross-sectional survey with a register-based follow-up: the DenHeart study protocol.
With the current study being a descriptive, hypothesis-generating study, we did not calculate a required sample size a-priori. Still, a sample size of n = 100 was considered to be adequate in addressing the association between clinical- and sociodemographic characteristics and the composite endpoint based on the included number of characteristics investigated separately.
Statistical methods
Baseline characteristics were presented as numbers and percentages for categorical variables. Continuous variables were tested for normality using the Shapiro-Wilks test. As the normality assumption was not met, continuous variables were presented as the median with the interquartile range (IQR, from the 25th to the 75th percentile). Differences in patient characteristics among responders and non-responders were compared using the Pearson χ2 –test for categorical variables and the Mann-Whitney U test for continuous variables.
The proportion of responders (part of the workforce) with symptoms of anxiety and depression (cut-off≥8) after discharge were presented as numbers and percentages.
A distribution plot was used to describe the pattern of sick leave and return to work 12 months after discharge, illustrating the differences in the proportion of patients on sick leave, part of the workforce and left the workforce up to 1 year following discharge.
Logistic regression analyses were performed to investigate the association between clinical- and sociodemographic characteristics, self-reported health at discharge (HRQoL, continuous scores of HeartQoL and symptoms of anxiety and depression, HADS-A and HADS-D ≥ 8) and the association with the composite endpoint (the endpoint of prolonged sick leave or leaving the workforce) at 3 and 12 months after discharge. The models were adjusted for the following potential confounders: sex, age and Tu-comorbidity score. Model fit was tested with the Likelihood Ratio. Results are presented as odds ratios (OR) with 95% confidence intervals (CI).
The p-value was assigned with a 5% significance level. All analyses were performed using STATA version 16.1 (StataCorp LLC, Texas, USA).
Ethics
The DenHeart study complied with the principles outlined in the Declaration of Helsinki
and was approved by the Danish Data Protection Agency (2007–58–0015/30–0937). The DenHeart study is registered at ClinicalTrials.gov (NCT01926145) and approved by the institutional boards of the participating Heart Centers. According to Danish Legislation, the survey does not require approval from the human ethics committee system. Written consent was given along with the questionnaire.
Results
Population
During the DenHeart study period, 572 OHCA patients were discharged from the five Heart centres. Of those, 81 were excluded due to illness or language barrier, resulting in a total population of 491 patients and n = 242 between 18 and 63 years and, thus, of a working age (Fig. 1). Among the working population, 58 were excluded due to early retirement, resulting in 184 patients being part of the workforce. Of those, the total workforce population, the majority, 76% (n = 139), were men, the median age was 51 years (IQR 43–57), and 60% (n = 110) were married (Table 1).
Table 1Sociodemographic and clinical characteristics among OHCA survivors in the total workforce population, and divided responders and non-responders (n = 184).
Information about BMI, smoking and alcohol consumption is based on self-reported data from DenHeart, and therefore presented only for responders (n = 176/n = 81).
BMI ≥ 25
53 (70)
53 (70)
N/A
BMI ≥ 30
18 (24)
18 (24)
N/A
Current daily smoker
9 (11)
9 (11)
N/A
Alcohol intake above high risk limit
<5
<5
N/A
BMI Body Mass Index, CABG coronary artery bypass grafting, IQR interquartile range, PCI percutaneous coronary intervention.
a All patients in a working age, 18–63 years (n = 184), divided into responders and non-responders.
b The p value was set at a 5% significance level.
c Information about BMI, smoking and alcohol consumption is based on self-reported data from DenHeart, and therefore presented only for responders (n = 176/n = 81).
The sub-analyses of responders of the workforce population (n = 81 patients, response rate 44%), revealed how responders were younger and had a higher educational level, compared with non-responders (Table 1).
Self-reported health
Table 2 depicts self-reported health (HRQoL, anxiety and depression) at hospital discharge among responders of the workforce population. Median scores of HeartQoL were: Global 2.07 (IQR 1.28–2.78), Physical 2.00 (IQR 1.20–2.80) and Emotional 2.50 (IQR 1.66–3.00). In addition, symptoms of anxiety at discharge were present among 33% (n = 25) (HADS-A ≥ 8) and symptoms of depression among 17% (n = 12) (HADS-D ≥ 8) (Table 2).
Table 2Self-reported health measured among responders of the working population (n = 81).
The pattern of sick leave and return to work following OHCA
The pattern of sick leave and return to work after discharge among the total population of patients being part of the workforce are illustrated in Fig. 2. Patterns of sick leave and return to work varied at different time points after discharge. At discharge, 60% (n = 110 were on paid sick leave, and 40% (n = 74) were registered as being working. At three months following discharge, 5% (n = 9) had left the workforce (due to early retirement, emigration or death), 43% (n = 80) were still on paid sick leave, and 52% (n = 95) had returned to work. At 12 months, 11% (n = 20) had left the workforce, 20% (n = 37) were still on paid sick leave and 69% (n = 127) had returned to work) (Fig. 2).
Fig. 2Labor market affiliation from discharge to 12 months
Total number of patients being part of the workforce (n = 184) and differences in proportions being on sick leave, working/part of the workforce or out of the workforce at a weekly basis up to 52 weeks after discharge.
Prolonged sick leave was experienced by 55% (n = 102) of the patients at 3 months and 60% (n = 111) at 12 months (not shown in Table/Figure).
Characteristics associated with prolonged sick leave or leaving the workforce
Among the total workforce population (n = 184), age (per one year older) increased the odds of the composite endpoint of prolonged sick leave or leaving the workforce at 3 months after discharge (OR 1.06 95% CI 1.03–1.10) and at 12 months after discharge (OR 1.06 95% CI 1.03–1.09). Sex, marital status, educational level or co-morbidities (heart failure, arrhythmias or ischemic heart disease) were not associated with the composite endpoint of prolonged sick leave and leaving the workforce at 3 and 12 months (Table 3).
Table 3The association between clinical and sociodemographic characteristics and the composite endpoint of prolonged sick leave and leaving the workforce at 3 months and 12 months.
Among the responders (n = 81), self-reported health (HRQoL, anxiety and depression) were not associated with the composite endpoint of prolonged sick leave and leaving the workforce at 3 and 12 months (Table 4).
Table 4The association between health-related quality of life, anxiety and depression and the composite endpoint of prolonged sick leave and leaving the workforce at 3 months and 12 months.
The current study demonstrated sick leave patterns following OHCA, with one-fifth of the survivors at a working age before the OHCA still on paid sick leave after 12 months. Similarly, we found increasing age to be a significant characteristic when investigating characteristics associated with a composite endpoint of prolonged sick leave or leaving the workforce within 3 and 12 months.
After 12 months, 69% of the population had returned to the workforce, similar to findings by Kearney et al.
), it is worth highlighting how the proportions of survivors returning to work after 12 months were similar. With paid sick leave and reimbursement strategies for the employer in the current Danish population,
Validation of sick leave measures: self-reported sick leave and sickness benefit data from a Danish national register compared to multiple workplace-registered sick leave spells in a Danish municipality.
we might have expected this to influence the proportion of survivors returning to work. But, after 12 months, this does not seem to be the case. Still, we speculate how unpaid sick leave might lead to an early return in countries with different policies and acknowledge how this could influence the results.
Interestingly, we demonstrated how increasing age was associated with the composite endpoint of prolonged sick leave or leaving the workforce at 3 and 12 months among the total workforce population. Higher age is a natural characteristic for leaving the workforce after a severe event caused by illness, as demonstrated by others.
But, although reaching retirement age is a natural cause of leaving the workforce, a recent qualitative study by Dainty et al. has explored OHCA survivors’ perspectives indicating that the OHCA has led to deliberate changes and redirections in life, and, for some, this meant withdrawal from work as a positive necessary step.
The participants in the study by Dainty et al. described how life had gained a new purpose: some were involved in volunteering, participated in the research, trained others in cardiopulmonary resuscitation and similar things related to the OHCA, whereas others again withdrew from the workforce to focus their time and energy on family, loved ones and other types of networks.
Thus, worth highlighting is, that returning to the workforce is not a primary goal for all people.
Prolonged sick leave occurred among 55% and 60% of the working population at 3 months and 12 months, respectively. Thus, we speculate how fatigue, cognitive impairment and reduced physical and mental health might lead to an increased period of sick leave, as seen in other studies.
To support this, the proportion of the working population with symptoms of anxiety was 33%, and therefore higher than we previously reported in another subpopulation of OHCA survivors of the DenHeart study (28%, with survivors both being part of the workforce before the OHCA and not).
This demonstrates how a younger working population might experience a higher burden of anxiety. Being mentally burdened after discharge might potentially influence working capacity, as working is a crucial marker of recovery among many OHCA survivors.
why it is crucial to detect mental symptoms that might influence the ability to work - to support the survivors in resuming their daily life.
Thus, the study has several implications for clinical practice and future research. First, to support OHCA survivors in resuming the workforce, targeted follow-up and rehabilitation following discharge are essential. As highlighted in a recently published study by Christensen et al., a more integrated rehabilitation program is needed to target OHCA survivors.
the authors suggest a rehabilitation program to include regular cardiac rehabilitation, but also neurological rehabilitation and psychological treatment to support the survivors in resuming work.
Similarly, this leads to implications for future research with an urgent need for new rehabilitation programmes for OHCA survivors to be developed and tested in randomized, controlled trials to investigate the effect on overall outcomes, including work status. In addition, more knowledge on factors associated with not returning to work is needed, as these elements might guide rehabilitation interventions and clinical practice.
Despite high proportions of symptoms of anxiety and depression at discharge, we did not find a significant association between these elements and the composite endpoint. However, this is presumable due to the low sample size of the subpopulation of responders, and we suggest future studies to investigate these perspectives more thoroughly.
Strengths and limitations
The study was conducted as a large, national multicenter study including patient-reported outcomes of OHCA survivors at discharge linked with register-based data. This enabled a complete dataset, including information on both responders and non-responders. The non-responders were older, had a lower educational level, and had a different primary diagnosis/cause of the cardiac arrest. In addition, the analyses were performed on a small population which might cause a problem in the regression analyses due to the lack of statistical power. The clinical data were obtained based on national registries, but data related to, e.g. intensive care unit was unavailable. These data would have strengthened the study.
When investigating the return to work, we used the DREAM register. This is both a main strength and a limitation of the study. The strength is that the registration is built on all entries of sick leave compensations. We expect these to be accurate as they are dependent on employers claiming compensation refunds (economic incentives). Contrary, a limitation is the inclusion of sick leave of more than two weeks. This means that short-term absence from work is not included. Similarly, the register do not distinguish between full- and part-time sick leave.
Validation of sick leave measures: self-reported sick leave and sickness benefit data from a Danish national register compared to multiple workplace-registered sick leave spells in a Danish municipality.
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.
Knowledge about job type and strain would also have been relevant but not available through the registries.
We limited the population to OHCA survivors between 18 and 63 years. We acknowledge, though, how survivors above the age of 63 might be working too, but the age limit was set to ensure that no patients received state pension during the follow-up period.
To conclude, one-fifth of the OHCA survivors at a working age prior to the OHCA were still on paid sick leave after 12 months. Increasing age was associated with a composite endpoint of prolonged sick leave or leaving the workforce at 3 and 12 months after discharge. In contrast, self-reported health at discharge, covering HRQoL, symptoms of anxiety and depression was not. With increasing survival rates following OHCA, healthcare professionals need to support the population in resuming daily life, including returning to the workforce, when relevant. Thus, knowledge of prolonged sick leave and the risk of not returning to the workforce following OHCA adds to the current evidence stating the need for targeted rehabilitation.
Funding
The overall DenHeart study was supported by the Danish Heart Centers and the Novo Nordisk Foundation. The current study received no additional funding.
Data availability statement
The data used in this article cannot be shared publicly due to Danish Law.
Declaration of Competing Interest
None
Acknowledgment
A special thanks to all the patients who took the time to fill out the questionnaires and all the cardiac nurses who assisted in the data collection at the Heart Centres.
References
Whitehead L.
Perkins G.D.
Clarey A.
Haywood K.L
A systematic review of the outcomes reported in cardiac arrest clinical trials: the need for a core outcome set.
Patient-reported outcomes at hospital discharge from Heart Centres, a national cross-sectional survey with a register-based follow-up: the DenHeart study protocol.
Validation of sick leave measures: self-reported sick leave and sickness benefit data from a Danish national register compared to multiple workplace-registered sick leave spells in a Danish municipality.
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.
Validity and reliability of the HeartQoL questionnaire in a large sample of stable coronary patients: the EUROASPIRE IV Study of the European Society of Cardiology.
The analyses are adjusted for sex, age and Tu co-morbidity index.
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