Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

The use of practice guidelines hastened patients' return to work after uncomplicated myocardial infarction only in those who did not have myocardial ischemia on treadmill testing

ACP J Club. 1993 Mar-April;118:58. doi:10.7326/ACPJC-1993-118-2-058


Source Citation

Pilote L, Thomas RJ, Dennis C, et al. Return to work after uncomplicated myocardial infarction: a trial of practice guidelines in the community. Ann Intern Med. 1992 Sep 1;117:383-9.


Abstract

Objective

To determine whether practice guidelines disseminated to community practice physicians hasten patients' return to work after uncomplicated myocardial infarction.

Design

Randomized controlled trial with 6-month follow-up.

Setting

Patients hospitalized in 4 Kaiser-Permanente coronary care units and cared for by primary care physicians after discharge.

Patients

187 patients (mean age 51 y, 92% men, 15% laborers) were selected from 902 patients hospitalized with acute myocardial infarction, diagnosed by elevated cardiac enzyme levels, characteristic electrocardiogram, and chest pain. Reasons for exclusion were age ≥ 61 years, not working before the infarct or planning an early retirement, or ineligibility for a symptom-limited treadmill test.

Intervention

95 participants were randomized to an Occupational Work Evaluation, including a symptom-limited treadmill test 10 to 21 days after the infarct, counseling by a nurse clinician and cardiologist emphasizing the potential for early return to work, and a standard consultation letter with an individualized recommendation about return to work. The primary care physician subsequently set a specific date for return to work. 92 patients were randomized to standard care, usually including treadmill testing.

Main outcome measures

Time to return to full-time work. Mailed questionnaires evaluating medical and occupational status were self-completed at baseline and 1, 3, and 6 months after the infarction. Subsequent cardiac events received blinded review by a cardiologist.

Main results

The mean time to return to full-time work was 60 days (median 54 d) for the intervention group and 64 days (median 67 d) for the usual care group (95% CI for the mean difference -6 to 14 d). In a post-hoc multivariate analysis, patients without myocardial ischemia in treadmill testing returned to work faster in the intervention group (mean 41 d) than in the usual care group (mean 61 d, CI for the difference 8 to 32 d). The groups did not differ when patients with myocardial ischemia were compared (mean 78 vs 74 d, CI for difference -16 to 24 d). The rate of recurrent infarction was 4% in each group; 2 cardiac deaths occurred in the intervention group.

Conclusion

Recommendations to primary care physicians based on practice guidelines hastened return to work after uncomplicated myocardial infarction among patients without myocardial ischemia on treadmill testing only, but not overall.

Source of funding: National Heart, Lung, and Blood Institute.

For article reprint: Dr. R.F. DeBusk, Stanford Cardiac Rehabilitation Program, 780 Welch Road, Suite 106, Palo Alto, CA 94304. FAX 650-723-6798.


Commentary

Can academic-developed practice guidelines for returning to work after acute myocardial infarction work in community-based primary care settings? A previous trial showed that risk stratification, symptom-limited stress tests, and patient counseling in a university research clinic with primary care follow-up reduced the return-to-work time when compared with usual care (1). What explains the failure of similar guidelines in community practices?

In the study by Pilote and coworkers, primary care physicians gave patients specified return-to-work dates after receiving calls from a study nurse; in the previous trial, patients received a call from a cardiologist. A follow-up consultation letter was used in both studies. Although return-to-work times were similar for those receiving the intervention in both studies, it was shorter for usual-care patients in the community than in the academic setting. Physicians may have followed guidelines in their practices regardless of patient allocation. Practice changes over time (e.g., a dramatic increase in the use of cardiac catheterization and coronary revascularization) may also have influenced the results.

Given the high variability in return-to-work times and limited sample size, the study by Pilote and colleagues may have lacked adequate statistical power. Differences were significant only for the low-risk subgroup and for patients without post-MI ischemia. These subgroup findings, along with the 1988 study, suggest that risk stratification may be effective in identifying low-risk patients who can return to work earlier. However, community practice changes over time, and the dissemination process, as well as the validity of the guidelines, requires careful consideration when academically developed guidelines are brought into community practices.

Jonathan N. Tobin, PhD
Clinical Directors Network of Region II, Inc.New York, New York, USA


Reference

1. Dennis C, Houston-Miller N, Schwartz RG, et al. Early return to work after uncomplicated myocardial infarction. Results of a randomized trial. JAMA. 1988; 260:214-20.