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


Prognosis

Patients' perceptions of their MI predicted return to work and functioning

ACP J Club. 1996 Nov-Dec;125:76. doi:10.7326/ACPJC-1996-125-3-076


Source Citation

Petrie KJ, Weinman J, Sharpe N, Buckley J. Role of patients' view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study. BMJ. 1996 May 11;312:1191-4.


Abstract

Objective

To determine whether patients' initial perceptions of their myocardial infarction (MI) predicts participation in cardiac rehabilitation, return to work, disability, and sexual dysfunction.

Design

Inception cohort followed for 6 months.

Setting

2 large teaching hospitals in New Zealand.

Patients

143 consecutive patients aged ≤ 65 years (mean age 53 y, 87% men, 89% European origin) who had been hospitalized with a confirmed first MI. Follow-up at 6 months was 80%.

Assessment of prognostic factors

Patients filled out questionnaires while in the hospital and at 3 and 6 months after hospitalization. Data were collected from 4 scales of the illness perception questionnaire that assessed the identity, time line, consequences, and cure or control dimensions that underlie patients' perceptions of their illness. Illness severity, anxiety, distress, age, days in hospital, and peak creatine kinase levels were also evaluated and analyzed as independent variables.

Main outcome measures

Attendance at a 6-session, outpatient, cardiac rehabilitation program; time to return to work; disability and function measured by the sickness impact profile; and sexual dysfunction.

Main results

By 6 months, 4 patients (3%) had died. Good psychological health was associated with low scores on all illness perception scales. Younger patients were more likely to perceive their MI as having negative effects on their lives. Patients who were less likely to believe that their illness could be cured or controlled did not attend the cardiac rehabilitation sessions (P = 0.04); no other variables were associated with attendance at sessions. 60 of 76 patients (79%) who had been employed full-time returned to work within 3 months of their MI. Patients who thought that their illness would last a short time (P = 0.01) and have less serious consequences (P = 0.005) returned to work earlier. Perception of illness at baseline predicted disability at 6 months. Perceptions of the consequences of their illness predicted patient functioning outside work. Patients who associated many symptoms with their illness were more likely to report sexual dysfunction.

Conclusion

Patients' initial perception of their illness after myocardial infarction predicted, to some degree, attendance at cardiac rehabilitation sessions, time to return to work, disability, and sexual dysfunction.

Source of funding: New Zealand Health Research Council.

For article reprint: Dr. K.J. Petrie, Department of Psychiatry and Behavioural Science, University of Auckland, School of Medicine, Private Bag 92019, Auckland, New Zealand. FAX 64-9-373-7493.


Commentary

This study assesses the relation between patients' early perceptions after their first MI and functional recovery within 6 months. Although initial patient perceptions and many other factors were compared with outcomes, only limited data were presented regarding changing patient perceptions over time. During hospitalization, correlations were documented between the length of stay, peak creatine kinase levels, and perception of how long the illness would last. During follow-up, baseline illness perception correlated with the degree of functional readaptation. The lack of confidence in a short illness duration or in less consequential illness was correlated with more subsequent disability and with nonattendance at rehabilitation sessions, but attendance at rehabilitation sessions was not associated with an earlier return to work. The authors postulate that modifying specific illness perceptions might facilitate readaptation.

This study confirms similar findings from other countries (1, 2) and raises important questions: Do perceived patient factors influence our choice of therapies early in the course of MI? Was inappropriate patient perception present on admission or was it a result of caregiver-patient interaction? Most important, can we modify patients' perception early in the disease?

This study does not address the relations among social issues, associated diseases,activity before MI, therapy type, whichpatients benefit the most from cardiacrehabilitation, or how cardiac rehabilitation influences patients' perceptions (3). It suggests that patients' perceptions influence recovery and that a questionnaire can measure the perceptions that may need to be addressed. As part of any therapy, we should support and encourage our patients' belief in a positive outcome.

Larry A. Weinrauch, MD
Mount Auburn HospitalCambridge, Massachusetts, USA


References

1. Hoffmann A, Pfiffner D, Hornung R, Niederhauser H. Coron Artery Dis. 1995; 6:147-52.

2. Boudrez H, De Backer G, Comhaire B. Eur Heart J. 1994;15:32-6.

3. Wenger NK, Froelicher ES, Smith LK. Cardiac Rehabilitation as Secondary Prevention. Quick Reference Guide for Clinicians. Clinical Practice Guideline #17. Agency for Health Care Policy and Research and National Heart, Lung and Blood Institute: Washington, D.C., 1995.