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Return to Work after Uncomplicated Myocardial Infarction: A Trial of Practice Guidelines in the Community

Louise Pilote, MD, MPH; Randal J. Thomas, MD, MS; Charles Dennis, MD; Patricia Goins, BSN; Nancy Houston-Miller, BSN; Helena Kraemer, PhD; Cheryl Leong; Walter E. Berger III, MD; Henry Lew, MD; Robert S. Heller, MD; Jonathan Rompf, MD; and Robert F. DeBusk, MD
[+] Article, Author, and Disclosure Information

Grant Support: By grant HL36734 from the National Heart, Lung, and Blood Institute of Health, Bethesda, Maryland.

Requests for Reprints: Robert F. DeBusk, MD, Stanford Cardiac Rehabilitation Program, 780 Welch Road, Suite 106, Palo Alto, CA 94304.

Current Author Addresses: Drs. Pilote, Thomas, Kraemer, DeBusk, Ms. Leong, Ms. Houston-Miller: Stanford Cardiac Rehabilitation Program, 780 Welch Road, Suite 106, Palo Alto, CA 94304.

Dr. Dennis: Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ 08015-1799.

Ms. Goins: 10666 N. Torrey Pines Road MLS SW 206, La Jolla, CA 92037.

Dr. Berger: Kaiser Permanente Medical Center, 1150 Veterans Boulevard, Redwood City, CA 94063.

Dr. Lew: Kaiser Permanente Medical Center, 900 Kiely Boulevard, Santa Clara, CA 95051.

Dr. Heller: The Permanente Medical Group, 27400 Hesperian Boulevard, Hayward, CA 94545.

Dr. Rompf: Kaiser Santa Theresa Community Hospital, 250 Hospital Parkway, San Jose, CA 95119.

©1992 American College of PhysiciansAmerican College of Physicians

Ann Intern Med. 1992;117(5):383-389. doi:10.7326/0003-4819-117-5-383
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Objective: To evaluate the effectiveness of practice guidelines for return to work after acute myocardial infarction when disseminated from a university-based setting to a practice-based setting.

Design: Randomized clinical trial.

Patients: A total of 187 patients with uncomplicated acute myocardial infarction.

Intervention: Patients were randomly assigned to the intervention (n = 95) or to usual care (n = 92). The intervention consisted of a treadmill test, a counseling session based on the test results, and a consultation letter from a cardiologist to the primary care physician. Individualized recommendations for the timing of return to work, contained in the consultation letter, were based on the patient's risk for recurrent cardiac events.

Measurements: Questionnaire, chart review, and a phone interview documented the timing of return to work and the rates of cardiac death, coronary angioplasty, coronary artery surgery, and recurrent myocardial infarction.

Results: Median intervals between acute myocardial infarction and return to work were similar in both groups (intervention, 54 days; usual care, 67 days; P > 0. 2). Among patients without myocardial ischemia, however, the interval was shorter in the intervention group than in the usual care group (38 days compared with 65 days, respectively, P = 0.008). Among patients with myocardial ischemia, intervals were similar in both groups (80 days compared with 76 days, respectively, P > 0.2).

Conclusion: Practice guidelines developed in a university-based setting were not as successful in hastening return to work after uncomplicated acute myocardial infarction when tested in a practice-based setting. Physicians' reluctance to follow guidelines for patients with myocardial ischemia reflected their concern with prognosis even though medical outcome was good.





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