Each year, more than 1 million Americans survive a heart attack or other coronary event. Getting them back to work effectively, safely and with an eye toward long-term health is paramount for employers in keeping medical costs down. A study presented recently to the American Heart Association concludes that the average short-term disability claim associated with acute coronary syndrome costs employers $7,943 in lost productivity alone; the average long-term claim, $52,473.

Cardiovascular disease remains the No. 1 killer in the United States, costing hundreds of billions of dollars a year in direct and indirect medical costs. Although preventing heart disease and heart attacks can and should be employers' primary focus, once a worker suffers a coronary crisis, how can a company aid the healing process and make sure that heart attack is a one-time thing?

Dr. Barry Franklin, director of the cardiac rehabilitation and exercise laboratories at William Beaumont Hospital in Detroit, recently spoke to EBN about the most effective and cost-saving cardiac rehab methods, as well as keeping workers from becoming patients again.


EBN: What can employers do to get employees back to work as safely and quickly as possible?

Franklin: Several things. The worksite environment is an ideal setting to help people make healthier lifestyle changes and to reduce or eliminate risk factors that can lead to cardiovascular disease. New studies suggest that, compared with 20 years ago, we're spending more time at the workplace - 170 hours more per year.

Specifically, what can [employers] do? Although I must admit, in full disclosure, I run a big cardiac rehabilitation program at William Beaumont Hospital, but the first thing I would encourage employers to do is allow patients to participate in a supervised, medically oriented, exercised-based cardiac rehabilitation program. Most of these programs typically last six-to-eight weeks, and the employee [participates] for one hour, three days a week. So, it's not an inordinate amount of time that the employee is away from work.

Secondly, I believe that employers should aggressively support employees getting involved in risk-reduction programs - for example, smoking cessation, diabetes education. I think an important point for your readers is to recognize that 75% to 90% of all cardiac events are attributed to traditional risk factors. [Those risks] include diabetes, cigarette smoking, hypertension, elevated blood cholesterol, obesity and physical inactivity.

And then lastly, in terms of mechanics, I want to promote the [American Heart Association]. The AHA has a program called Start [that] encourages worksites to promote a healthy environment by offering employees more healthy nutritional choices, more options for physical activity ... and promoting a wellness culture.



EBN: What does your rehabilitation program entail?

Franklin: First, patients enter at the recommendation of their primary care physician or cardiologist. Second, they're typically evaluated with a road test or a graded-exercise stress test - it could be done in their doctor's office - so we can get some indication of how their heart responds after the coronary event or after the bypass surgery to progressive levels of effort. Third, we design an individualized program, and my bias is that, for people who've had heart disease - and the literature supports this - one of the single best indicators of outcome, prognosis and subsequent health care costs is the patient's fitness level, cardiorespiratory heart/lung fitness level.

We categorize fitness in terms of what we call METs, or metabolic equivalents. Sitting here at rest, we're each taking in one unit of oxygen, that's called a "MET." Many cardiac patients' stress tests typically achieve six to eight METs. We know that less than five METs is associated with a very poor prognosis; we know that greater than eight-to-nine METs is associated with a very good prognosis, irrespective of the type of heart attack they've had or the procedure they've had. So, in many respects, it really is survival of the fittest.

Then we look at the AHA's secondary prevention guidelines, identify risk factors that the patient has, work with the patient and the referring physician in tandem to facilitate global cardiovascular risk reduction. Some of the things that we're interested in: What is the patient's cholesterol value? Are they on a healthy diet? If they're not, are they on drug therapy to help them achieve that healthy cholesterol level?

[Regardless of the rehab program], the single most important determinant of [a patient's] outcome is probably the person they see in the mirror every day. Doctors are important, hospitals are important, but they've got to take responsibility for identifying risk factors, hopefully in tandem with their employer or their private prevention or their cardiologist, and aggressively modifying those risk factors.


EBN: Let's talk about stress. Other than adjusting workloads, expectations and output, how can employers help employees lower stress?

Franklin: There was an article several years ago in the Journal of the American Medical Association that highlighted the fact that workers who had heart attacks, went back to work and reported high levels of stress over a six-year period were twice as likely to experience a second heart attack.

I think one way [to lower stress] is giving employees some diversification from day-to-day responsibilities - for example, the opportunity to exercise over the noon hour. By exercising, we unequivocally lower stress levels. The days of the 60- and 70- and 80-hour workweek should really be tapered down. People, if they are given more time, feel under less stress. And rewarding small accomplishments over a long period of time would be critically important.


EBN: How can we get the costs of all this down?

Franklin: According to recent research, costs for cardiovascular disease are expected to triple in the next 20 years. The cost a year and a half ago was about $300 billion; it's expected to go to $900 billion by 2030.

Where are a lot of those billions going? Seventy-five cents out of every dollar is going to treat chronic disease, and a big portion of that money is being spent on, in my humble opinion, procedures that don't always have to be done, like bypass surgery [and] angioplasty.

Lots of new studies suggest that for clinically stable patients, medical management - that is, aspirin, statins, beta-blockers, weight reduction, regular exercise - can be just as effective in promoting favorable outcomes as the more expensive, high-priced surgical-type procedures. So, employers need to invest in prevention.



EBN: What are the common factors among workspaces where people recover well and are less likely to have a second heart attack?

Franklin: Well, certainly one of the things is having an understanding and compassionate supervisor, who recognizes that by working on health promotion for his or her employees, ultimately it's going to save the company money. It's workplaces that stress healthy nutritional choices; it's workplaces that encourage their employees to be physically active; and it's workplaces that promote a wellness culture ... and allow workers some flexibility in terms of their hours.

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