Perceived return-to-work pressure following cardiovascular disease is associated with age, sex, and diagnosis: a nationwide combined survey- and register-based cohort study

Despite improved survival, cardiovascular disease (CVD) remains a leading cause of mortality and increased disease burden in Europe and is increasingly common in the working-age population [1, 2]. In Denmark, more than 56,000 people are diagnosed with CVD each year [3], and according to The Danish Heart Statistics approximately 36% of these are between 35 and 65 years old [3, 4]. Hence, a great proportion of people living with CVD is of working-age, and for these people facilitating return to work is a key rehabilitation goal, because employment is highly valued by individuals and societies [5‐7].

Cardiac rehabilitation may facilitate return to work [8, 9], and international recommendations include vocational counselling as part of comprehensive rehabilitation programmes [10]. However, most European countries do not have clear guidelines [9], and more emphasis on vocational rehabilitation is needed [9, 11]. The aim of cardiac rehabilitation is to improve health and quality of life and allow people, as far as possible, to return to their activities of daily living [12], and for employed people with CVD work resumption is an important aspect of returning to normality [13‐16]. Return to work is associated with better psychosocial well-being and health related quality of life [16], and is of great importance for social relationships, income and purpose in life [15]. Return to work is a complex process shaped by a range of factors including personal characteristics, the severity of the disease, work-related factors (e.g., job position and working conditions), national compensation policies, and the structure of the healthcare system (e.g., access to rehabilitation programmes and vocational counselling) [17, 18]. Previous studies have demonstrated that CVD affects the ability to work and that return-to-work rates are moderate with variation across countries and patient groups [8, 9, 18‐22]. Risk factors associated with failure to return to work after CVD include female sex [19‐21, 23], older age [21, 23], severity of the disease [20, 24], comorbidities [19‐21, 23], lower educational level [19‐21], and low income [19, 21]. Additionally, type of employment and occupational requirements, such as white or blue-collar work [8, 9], night shifts, and the ability to commute shape return-to-work [9]. Researchers have also documented that many people with CVD struggle with sustaining employment after initial return to work [19, 20, 22], have difficulties with returning to work at the pre-CVD level [13], and experience a number of barriers for returning to work, such as physical and mental incapacity, co-morbidities, unfavorable terms of employment, and motivational problems [13].

Struggles with returning to work and sustaining employment may be due to insufficient vocational rehabilitation, which results in patients feeling compelled to return to work while they are still recovering. To support people who are returning to work, help them continue their employment, and provide cardiac rehabilitation, we need to identify those in need of vocational rehabilitation. To improve our understanding of the return-to-work experience of people with CVD, we conducted a nationwide survey and linked the responses with register data. We investigated the likelihood of patients feeling under pressure to return to work and investigated whether this was influenced by sex, age, or CVD diagnosis. The results provide valuable insights, which may be used to improve targeted vocational rehabilitation and facilitate return to work after CVD.

Figure 1 shows the selection of the study population. The overall response rate in the Life With Heart Disease Study was 51.1%. Of the total respondents to the survey, 1,683 (35.3%) reported being in employment at the time of diagnosis; among these, 1,564 (92.9%) respondents reported having been on sick leave. Of these, 842 respondents (53.8%) had returned to work and were, therefore, included in the study population. Compared with respondents, the non-respondents were more likely to be female (53.3% vs. 47.4%, p < 0.001), have a higher mean age (68.6 vs. 67 years, p < 0.001), a lower educational level (p < 0.001), a lower mean income (p < 0.001), and have been born outside of Denmark (p < 0.001).

In this nationwide combined survey- and register-based cohort study including people diagnosed with CVD during 2018, 842 respondents (53.8%) had returned to work when they answered the survey performed between October 2020 and February 2021. This return-to-work rate is lower than that reported by other studies [18‐22], probably because our population had an older mean age than most previous studies. We investigated the likelihood of individuals feeling under pressure to return to work. The wording used to describe this pressure in Danish has negative connotations, and this was confirmed during our cognitive interviews. Almost one-third of respondents (29.7%) reported that they had felt under pressure to return to work, and we found that this experience was common across CVD diagnoses. Our results are probably most applicable to other welfare state nations, because patients’ economic and social-security safety nets, which affect the return to work [18], are shaped by the characteristics of each particular country. However, some patterns emerged that may inform the provision of cardiac rehabilitation programmes across western nations in general, improving the return-to-work experience.

First, our findings imply that returning to work may be more challenging for people diagnosed with HVD or HF than for those diagnosed with AF or IHD. This observation may be due to differing adverse effects on physical and mental health following CVD that are associated with each particular condition [31], and this finding is consistent with results from previous studies that reported higher return-to-work rates among people diagnosed with, for example, AF than HF [20, 22]. However, because the observed differences are modest, our findings suggest that vocational rehabilitation should not target particular patient groups, but rather focus on the individual’s ability to return to work and perform specific occupational tasks. The need for such an approach is demonstrated by the high prevalence of comorbidities (79.6%) and supported by a recent systematic review and meta-analysis that advocated focusing rehabilitation on each individual’s disease and condition [8].

Second, our findings indicate that people with CVD who are aged 55 years or younger are more likely to feel under pressure to return to work than people who are older than 55 years. This may be because younger people are less financially stable and more likely to have children living at home than older people. In addition, younger people may feel more susceptible to work-related factors. For example, employers may be more willing to retain senior employees who have more experience in that particular workplace. Furthermore, younger people may feel more pressure to return to work because they have more years left on the labour market and perhaps have higher career aspirations than people who are closer to retirement. Prolonged sickness absence is a major risk factor for permanent labour market exclusion [32], and returning to work following CVD may be especially important for younger people, who potentially have many years to work in the future. On the other hand, older people have a higher risk of permanent exclusion from the labour market due to ageism [33].

Third, our findings imply that women are more likely to feel under pressure to return to work than men. Regardless of their occupational status, women may take greater responsibilities for housework and caring duties at home [34], and this may increase their perceptions of pressure to return to work. In addition, more women than men reported a need for professional vocational counselling, and our findings indicated that women were more likely than men to return to work before feeling mentally and/or physically ready. This is a worrying observation and it is consistent with previous findings, which showed that many people with CVD, and particularly women, report a lack of psychosocial healthcare [35].

Overall, our study indicates that younger women may need special attention in cardiac rehabilitation, as suggested by previous studies [34]. Other authors have reported that women exhibit lower self-efficacy, lower quality of life, and greater psychological distress than men at the time of a first cardiac event or at the onset of rehabilitation [34, 36]. Furthermore, a recent review concluded that return to work is more strongly determined by psychosocial parameters than by the underlying cardiac disease [9], and there is strong evidence that anxiety and depression, which are common among people with CVD [37] have a negative impact on return to work [38]. Therefore, to facilitate a patient’s return to work all core rehabilitation components, including psychosocial support, must be considered. The value of combined programmes that include both exercise and counselling components, as well as individually delivered psychosocial and vocational interventions, has been demonstrated in recent reviews and meta-analyses [18, 39]. In addition, our results indicate that many people with CVD return to work before they feel ready. Therefore, vocational rehabilitation should, as suggested by other authors [19, 22], encompass employment maintenance to prevent reoccurrence of sick leave. Here, tele-rehabilitation may be a valuable approach, because this allows people to restart work while undergoing rehabilitation [9]. Moreover, to overcome some of the barriers to participation experienced by younger people (e.g., work responsibilities, time constraints and family responsibilities [40]), rehabilitation programmes need to be flexible and designed to suit the individual’s needs and preferences. Overall, tailored cardiac rehabilitation programmes are needed that reflect diversity in terms of disease severity and type, risk profile, age, sociocultural traditions, and everyday life situations [41].

In this study, the respondents indicated that job counselling centres were the most frequent source of pressure to return to work. In Denmark, all Danish citizens are entitled to paid sick leave, and job counselling centres are responsible for the administration of sickness absence. This finding is particularly relevant for the Nordic welfare state nations, but respondents also reported other sources of pressure (e.g., from their employer). This finding supports the creation of multidisciplinary and coordinated cardiac rehabilitation programmes that encourage relevant stakeholders (e.g., employers, social workers, rehabilitation nurses and physiotherapists) to develop individualized return-to-work plans. Such an approach may hold potential for improving vocational rehabilitation across Europe, where many countries currently lack clear guidelines [9].

Finally, in addition to feeling both pressured and unready to return to work, we found that half of our respondents who expressed a need for professional vocational counselling reported that these needs were unmet. Therefore, similar to previous European studies [9, 42], our results imply that current vocational cardiac rehabilitation programmes are inadequate and that a greater focus on this component is warranted.

In this nationwide combined survey- and register-based study, almost one-third of the study population reported that they had felt under pressure to return to work. In addition, our findings indicated that many people with CVD return to work before they feel physically or mentally ready, and that their needs for vocational rehabilitation are not being met. Pressure to return to work was associated with age, sex, and CVD diagnosis, and our results suggest that more flexible, person-centred return-to-work interventions that can meet diverse needs are required for this patient group. In addition, our study emphasizes the value of multidisciplinary and coordinated interventions that involve relevant stakeholders, as well as the importance of ensuring that cardiac rehabilitation programmes include all core rehabilitation components, including both psychosocial support and vocational rehabilitation.