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Early discharge and return to work following myocardial infarction

By Miriam J. Stewart and Frances M. Gregor

Abstract

Individuals who have experienced a myocardial infarction (MI) account for the largest component of all hospitalization costs and foregone earnings due to cardiac disease. Early return to full employment and premorbid activity level should be the focus of cost-effective rehabilitative programs. Yet the economic benefits of vocational rehabilitation have not been directly researched. Therefore, issues of import regarding activity after MI include the timing of ambulation, discharge and return to work. Studies of early mobilization and discharge are contrasted in terms of methodology and outcome. These cite economic, social and psychological advantages, yet these factors are examined in isolation of other variables. A review of the literature reveals that there is a reluctance by many health professionals to institute such practices based in part on the dilemma surrounding selection of specific indicators and risk factors. Yet analysis reveals that the contention surrounding these exclusion criteria is perhaps unfounded, as the variance is less than is commonly assumed. Recurrent themes likewise emerge regarding the multiplicity of variables associated with the timing of resumption of employment, which is considered to be the most precise index of recovery following an MI. Of these, only early intense rehabilitation, directed at attitudinal and behavioural change, is amenable to modification by health professionals. Related research endeavours have examined employment following aortocoronary bypass surgery, risk factors in the work environment and work stressors which occur following MI. Controversy arises regarding the correlation of age and personality factors with return to work. Discrepancies in research findings are attributed to the diverse approaches to data collection, obstacles encountered in measuring psychological states, lack of operational definitions, differences in degree of rehabilitation and length of follow-up and the absence of controlled trials. Clearly, experimental research focusing on the job-related economic and human cost impact of specific rehabilitation programs must be conducted. Three strategies are identified which should facilitate return to premorbid levels of activity, including (1) the definition, development and integration of roles of diverse professionals within the interdisciplinary health care team, (2) the early detection and modification of psychological problems, physical disability and inappropriate occupations which would prevent MI patients from returning to their former occupations and (3) prompt follow-up and comprehensive structured rehabilitation programs which incorporate education, exercise and emotional support at the individual, family and community level. This analytical survey supports the principle of early mobilization, discharge and return to employment or premorbid state, yet operational definitions and deadlines are only in the infancy stage. Multidisciplinary experimental efforts must be directed toward the detection of significant variables and generalizable rehabilitation mechanisms. The process of programs requires testing as do the emotional, physical and health outcomes.

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