Employment status after coronary artery bypass surgery

Value of robotically assisted surgery for mitral valve disease

IMPORTANCE

The value of robotically assisted surgery for mitral valve disease is questioned because the high cost of care associated with robotic technology may outweigh its clinical benefits.

OBJECTIVE

To investigate conditions under which benefits of robotically assisted surgery mitigate high technology costs.

DESIGN, SETTING, AND PARTICIPANTS

Clinical cohort study at a large multispecialty academic medical center comparing costs of robotically assisted surgery with 3 contemporaneous conventional surgical approaches for degenerative mitral valve disease. From January 1, 2006, through December 31, 2010, a total of 1290 patients with a mean (SD) age of 57 (11) years underwent mitral valve repair for regurgitation from posterior leaflet prolapse. Robotically assisted surgery was performed in 473 patients, complete sternotomy in 227, partial sternotomy in 349, and anterolateral thoracotomy in 241. Comparisons were based on intent to treat, with 3 propensity-matched groups formed based on demographics, symptoms, cardiac and noncardiac comorbidities, valve pathophysiologic disorders, and echocardiographic measurements: robotic vs sternotomy (198 pairs) vs partial sternotomy (293 pairs) vs thoracotomy (224 pairs).

INTERVENTIONS

Mitral valve repair.

MAIN OUTCOMES AND MEASURES

Cost of care (expressed as robotic capital investment, maintenance of equipment, and direct technical hospital costs) and benefit of care (based on differences in recovery time).

RESULTS

Cost of care (median [15th and 85th percentiles]) for robotically assisted surgery exceeded that of alternative approaches by 26.8% (-5.3% and 67.9%), 32.1% (-6.1% and 69.6%), and 20.7% (-2.4% and 48.4%) for complete sternotomy, partial sternotomy, and anterolateral thoracotomy, respectively. Higher operative costs were partially offset by lower postoperative costs and earlier return to work: a median (15th and 85th percentiles) of 35 (19 and 63) days for robotically assisted surgery, 49 (21 and 109) days for complete sternotomy, 56 (30 and 119) days for partial sternotomy, and 42 (18 and 90) days for anterolateral thoracotomy. Resulting net differences (median [15th and 85th percentiles]) in the cost of robotic surgery vs the 3 alternatives were 15.6% (-14.7% and 55.1%), 15.7% (-19.4% and 51.2%), and 14.8% (-7.4% and 43.6%), respectively. Beyond a volume threshold of 55 to 100 robotically assisted operations per year, distribution of the cost of this technology broadly overlapped those of conventional approaches.

CONCLUSIONS AND RELEVANCE

In exchange for higher procedural costs, robotically assisted surgery for mitral valve repair offers the clinical benefit of least-invasive surgery, lowest postoperative cost, and fastest return to work. The value of robotically assisted surgery that is similar to that of conventional approaches can be realized only in high-volume centers.

Work Status and Return to the Workforce after Coronary Artery Bypass Grafting and/or Heart Valve Surgery: A One-Year-Follow Up Study

Background. Several characteristics appear to be important for estimating the likelihood of reentering the workforce after surgery. The aim of the present study was to describe work status in a two-year time period around the time of cardiac surgery and estimate the probability of returning to the workforce. Methods. We included 681 patients undergoing coronary artery bypass grafting and/or heart valve procedures from 2003 to 2007 in the North Denmark Region. We linked hospital data to data in the DREAM database which holds information of everyone receiving social benefits. Results. At the time of surgery 17.3% were allocated disability pension and 2.3% were allocated a permanent part-time benefit. Being unemployed one year before surgery reduced the likelihood of return to the workforce (RR = 0.74 (0.60-0.92)) whereas unemployment at the time of surgery had no impact on return to the workforce (RR = 0.96 (0.78-1.18)). Sickness absence before surgery reduced the likelihood of return to the workforce. Conclusion. This study found the work status before surgery to be associated with the likelihood of return to the workforce within one year after surgery. Before surgery one-fifth of the population either was allocated disability pension or received a permanent part-time benefit.

Return to Work After Coronary Artery Bypass Surgery in a Population of Long-Term Survivors

BACKGROUND

Return to paid employment may be facilitated by coronary artery bypass graft (CABG) surgery. We assessed work status in a population-based study of long-term outcomes of CABG.

AIM

To determine the association between returning to work after CABG and clinical and socio-demographic factors.

METHODS

A postal survey of 2,500 randomly selected patients 6-20 years post-CABG. The outcomes assessed were work status in the year before and after CABG and health-related quality of life (HRQOL) measured with SF-36.

RESULTS

Response was 82% (n = 2,061). Employment fell from 56% in the year prior to CABG to 42% in the year after. Workers in 'blue-collar' occupations were more likely to reduce their work status than those in 'white collar' occupations (46% versus 29%, p < 0.001). Independent predictors of reducing employment were increasing age (9% per year, 99% CI: 1.06-1.11, p < 0.001), 'blue-collar' versus 'white collar' occupation (OR: 2.1, 99% CI: 1.4-3.1) and female sex (OR: 2.1, 99% CI: 1.1-3.6). HRQOL among participants under 60 years of age at follow-up was better for those who returned to work after CABG surgery.

CONCLUSION

CABG surgery is followed by a net loss to paid employment of working age patients which increases with age, and is more likely for those in blue-collar occupations and women.

Quality of life and return to work 5 years after coronary artery bypass surgery. Long-term results of cardiac rehabilitation

BACKGROUND

Rehabilitation is an important part of the treatment of patients with ischemic heart disease. Therefore, many patients undergoing coronary artery bypass surgery (CABS) also participate in cardiac rehabilitation programs. This study was conducted to investigate whether rehabilitation influences quality of life and work status after CABS.

METHODS

Consecutive patients undergoing elective CABS were randomly assigned to a rehabilitation group (R, N = 119) and a hospital-treatment group (H N = 109). All patients received usual medical care. Group R participated in a rehabilitation program based on exercise and counseling. The follow-up time was 5 years. The measured domains of health-related quality of life were heart symptoms, functional class, exercise capacity, use of medication, depression, the patients' perception of health, and overall life situation. The Nottingham Health Profile as a measure of perceived distress was used.

RESULTS

Symptoms, use of medication, exercise capacity, and depression scores did not differ between groups R and H. Five years after the CABS, the patients in group R reported less restriction in physical mobility on the Nottingham Health Profile than patients in group H (P = 0.005), and more patients in group R than in group H perceived their health (P = 0.03) and overall life situation (P = 0.02) as good. The increase in the proportion of subjects working was higher in group R than group H at 3 years after the CABS (P = 0.02), but not at other follow-up times.

CONCLUSION

A cardiac rehabilitation program in conjunction with usual medical care after CABS may induce a perception of improved health. The influence on return to work is limited.

Subjective quality of life measures for evaluating medical intervention

Medical interventions are usually evaluated in terms of mortality and morbidity data, but there is recent interest in going beyond medical data to assess the impact of the therapy on the objective and subjective quality of the patient's life. Objective quality of life measures such as employment and functional status are relatively straightforward, but measuring subjective quality of life is a more complex task. This article reviews psychometric issues relevant to using subjective quality of life scales developed by Bradburn and by Campbell, Converse, and Rodgers for research with patient populations. The evidence indicates that these relatively brief scales assess both affective and cognitive aspects of subjective quality of life, that they are measuring something more stable than mood but less enduring than personality, and that they can be as sensitive as physiological measures in distinguishing among treatment groups. It is concluded that these scales offer a useful complement to more objective measures of patient status for research evaluating medical interventions.

Sexual activity after coronary bypass surgery

Although successful rehabilitation of coronary artery bypass surgery (CABS) patients should include consideration of their sexuality, there is a paucity of data regarding their sexual activity (SA). One hundred thirty-four patients were interviewed in regard to the impact of surgery on their sexuality and the relation of SA to their work status. Eighty-four of the 92 previously sexually active patients and two of the inactive ones resumed SA. Sexual dissatisfaction prior to surgery was a negative factor (p less than .05), while return to work, in the group that was working before, was positive (p less than .05) for resumption of SA. The average time before resumption of SA after CABS was 7.8 weeks. Thirty-nine percent of patients decreased the frequency of SA. Seventeen percent of patients and 35 percent of their partners expressed fear of resumption of SA. Twenty-three percent of patients had symptoms during intercourse. The couples who resumed sexual activity had a closer emotional relationship (p less than .02). Two-thirds of the patients received sexual instructions, but in only 20 percent of the cases did the physician himself initiate discussion. Although after CABS patients fare much better in regard to SA when compared to myocardial infarction patients reported in other studies, CABS does not provide a net gain in SA and sexual functioning. Comprehensive sexual counseling is still not being adequately addressed.

Medical, psychological and social correlates of work disability among men with coronary artery disease

This study identifies the medical, psychologic and social factors that independently affect employment in patients with coronary artery disease (CAD). At coronary angiography, extensive clinical, psychological and social profiles were collected on 814 men younger than 60 years with documented CAD. Clinical factors studied included measures of symptom severity, prior myocardial infarction, coronary anatomy and left ventricular function. Psychosocial factors studied included the Minnesota Multiphasic Personality Inventory (MMPI), Zung Depression and Anxiety Scales, a type A structured interview, Jenkins Activity Survey and measures of education and social support. Multiple logistic regression analyses were used to assess the relative strength of the relation between these different factors and the patients' employment status. Many single factors differed between the 204 men (25%) who were disabled and the 610 (75%) who were not. Disabled men were less educated but no different in age, marital status or number of dependents. Disabled men had lower ejection fractions and higher indexes of angina, previous myocardial infarction and coexisting vascular disease. Disabled men also were more depressed and anxious and had lower ego strength and higher hypochondriasis scores on the MMPI, but were no different in type A behavior. By multivariable analysis, the most significant (p less than 0.01) independent predictors of work disability were, in decreasing order of importance, low education level, history of myocardial infarction, high levels of depression and high levels of hypochondriasis. It is concluded that psychological and social factors are strongly related to work status in patients with CAD, and may be more important than medical factors.

Relationships of working status and cardiac capacity to functional age before and after coronary bypass surgery

In 77 patients having coronary bypass surgery, we evaluated the interaction between chronological age, functional age, and working status pre- and postoperatively. Preoperatively the chronological age of those not working compared to those working was 60.7 +/- 8.4 years versus 53.0 +/- 8.3 years (P less than 0.001). The preoperative functional ages were 93.5 +/- 11.5 versus 87.6 +/- 10.9 years (P less than 0.05). Postoperatively no patient who was not working preoperatively started work, although functional age improved from 93.5 +/- 11.5 to 83.2 +/- 12.8 years (P less than 0.001). Postoperatively subjects who stopped working showed similar improvement in maximal cardiac output, and maximal oxygen consumption compared to those who continued working; however, the functional age after surgery was 80.6 +/- 9.4 versus 69.6 +/- 11.6 years (P less than 0.01). This study showed a poor relationship between degree of improvement in cardiac function after bypass surgery and change in working status. However, functional age and chronological age contribute to the poor results with regard to return to work.

Coronary artery surgery study (CASS): a randomized trial of coronary artery bypass surgery. Quality of life in patients randomly assigned to treatment groups

To evaluate the comparative effects of medical and surgical therapy on quality of life of patients with stable ischemic heart disease, 780 patients who had been randomly assigned to medical or surgical therapy in the CASS were systematically followed for a mean of 5.5. years. Analysis was performed according to original treatment assignment. Patients in the surgical group had significantly less chest pain, fewer activity limitations, and required less therapy with nitrates and beta-blockers. Treadmill exercise tests performed 6, 18, and 60 months after entry documented significantly longer treadmill time, less exercise-induced angina, and less ST segment depression among surgical group patients. However, employment status and recreational status did not differ significantly between medical and surgical groups. Total number of hospitalizations after randomization was higher in the surgical group owing primarily to rehospitalization during the first year of follow-up for the coronary artery bypass graft surgery. Risk factors, including high blood pressure, cigarette smoking, high cholesterol levels, overweight, and poor exercise habits remained similar between medical and surgical groups. This randomized collaborative study shows that coronary artery bypass graft surgery improves the quality of life as manifested by relief of chest pain, improvement in both subjective and objective measurements of functional status, and a diminished requirement for drug therapy. However, no significant effect on employment or recreational status was observed.

Psychosocial coping strategies and cardiac capacity before and after coronary artery bypass surgery

One hundred patients, eighty-nine men and eleven women, with chronic stable angina who were previously selected for aortocoronary bypass grafting gave informed consent for non-invasive and invasive testing of hemodynamic responses to symptom-limited maximal exercise before surgery. Psychosocial coping strategies were evaluated preoperatively by structured interviews and assessment of patients perceptions of symptoms (Cornell Medical Index) and life changes (Holmes and Rahe Schedule of Recent Experiences). Preoperatively forty-one patients were "compartmentalized," forty-two "generalized" and seventeen "vacillated" according to Josten's classification of coping strategies. The Berle Index of social assets was lower and the prevalence of psychiatric symptoms (Cornell categories M to R) was greater in the vacillators preoperatively. Despite less ischemic ST depression in vacillators, no other significant physiological differences were noted between these categories preoperatively. Postoperatively more of the vacillators refused follow-up evaluation, and of vacillators who returned, only one-half were adequately revascularized at operation. Of sixty-five reevaluated after surgery, eight improved, twelve worsened and forty-five did not change classification of coping strategies, yet physiological variables of cardiac function when invasively measured in sixty patients were significantly improved in all three groups. Amounts of improvement, both absolutely and relative to sex- and age-adjusted normal values, were least in vacillators with virtually normal cardiac capacity, and/or inadequate revascularization. Compartmentalized patients were more frequently working, yet only sixty-four in all psychosocial classifications worked before surgery. After this event only forty-five resumed working; none of the non-workers or retired returned to work. Both physiologic improvement and working status were independent of postoperative psychosocial status.