Cardiovascular disease and absenteeism in Dutch occupational health: a retrospective study in a regular working population

The impact of cardiovascular disease (CVD) on employment capabilities and its associated costs for businesses and society has been poorly investigated. CVD is the foremost cause of mortality globally, and it’s associated with high morbidity [1]. Among all types of CVD, ischemic heart disease (IHD), cerebrovascular disease, and peripheral arterial disease (PAD) are the most prevalent.

There is a lack of current data on the precise incidence of CVD-related absenteeism and the additional costs incurred by companies or society due to absenteeism caused by CVD. Previous research has shown that CVD significantly contributes to increased workplace absenteeism [2‐7]. Currently, the only available data are on IHD specifically. In 2002, the average absenteeism duration after IHD was 189 days in the Netherlands, and globally the average absenteeism duration after myocardial infarction varied from 38 days to 177 days [8]. In a Swedish publication, covering the years 2006–2008, the adjusted mean absenteeism days were 83.9 (95% CI 80.6–86.5) during the first year after an IHD event, and after stroke these were 179.5 (95% CI 172.4–186.8) days [5]. The occurrence of IHD led to a six-fold increase in absenteeism days, and the occurrence of stroke led to a 14-fold increase compared to the absenteeism days prior to the event [5].

Therefore, following an acute cardiac event, return-to-work (RTW) represents a vital patient-reported outcome (PROM) of interdisciplinary disease management [4]. Cardiac rehabilitation (CR) supports patients in recovering and RTW after acute coronary events, particularly through a multidisciplinary approach that includes medical, physical, psychosocial, and vocational support [9]. Despite this, many working-age patients do not successfully reintegrate into employment after CR, leading to reduced quality of life and societal costs [9]. Importantly, studies also show that RTW is more influenced by other PROMs—such as expectations, anxiety, and quality of life—than by clinical measures. Other factors, such as comorbidities, low education, and negative beliefs, hinder RTW while endurance training, higher education, and perceived work stress can facilitate RTW [9, 10]. With an aging workforce and rising retirement age, the burden of CVD on society is expected to grow, making effective vocational reintegration increasingly important (Fig. 1).

We extracted routinely collected absenteeism data from 2019–2022 from a database maintained by two large, nationally operating Dutch Occupational Health Services (OHSs; both are part of HumanTotalCare BV).

In this exploratory study, we used standard-of-care data from two major occupational health services in the Netherlands to examine absenteeism due to cardiovascular disease (CVD) within a large cohort of the Dutch working population from 2019 to 2022. We observed a 3.2% incidence of absenteeism due to CVD, a median absenteeism duration of 119 working days, and a minimum rough cost-estimate for employers of around € 37,000 per employee. Of all CVD diagnoses, cerebrovascular disease was found to be associated with the longest absenteeism duration. For reference, in the Netherlands two frequently occurring causes of absenteeism or work disability are stress-related illness (average absenteeism duration 101 working days; average cost to the employer of € 19,151 per employee [11]) and low back pain (median absenteeism duration 95 days; mean cost to the employer of € 15,350 per employee [17]).

In our study acute myocardial infarction (AMI) and cerebrovascular disease were the two most frequently occurring diagnoses, with an average absenteeism duration of 128 days and 185 days, respectively. These absenteeism durations are quite similar to earlier findings, thus even though medical care has evolved over time, AMI and cerebrovascular disease are still associated with a relatively long absenteeism duration. This highlights the critical importance of focusing rehabilitation efforts on achieving return-to-work (RTW) after AMI and cerebrovascular disease. Effective rehabilitation can help employees resume work, enhance their quality of life, and reduce absenteeism costs.

RTW rates within 12 months after acute coronary syndrome (ACS) range from 67–93%, with an average delay of 2–3 months. Kruse et al. reported 79% RTW after coronary heart disease (CHD) admissions versus 93% after other diagnoses [2]. In our study, approximately 86% of employees returned to work within 6–12 months following AMI. RTW outcomes after CVD are influenced by medical (e.g., ventricular function, ischemia, rhythm stability), occupational (e.g., physical demands, shift work, commuting), and psychosocial factors (e.g., depression, self-perceived health, cognitive impairments) [18, 19]. A multinational review identified six barriers (job strain, anxiety, depression, comorbidity, older age, low education) and four facilitators (job control, work ability, good perceived health, high socioeconomic status) to RTW after CVD [19]. Non-fatal CHD is associated with increased absenteeism, presenteeism, delayed RTW, early labour force exit, and unemployment, challenges that likely extend to AMI survivors, who also face risks such as reduced job responsibilities, part-time work, lower income, and dismissal [5, 19].

Cardiac rehabilitation (CR) uptake in the Netherlands is suboptimal. A nationwide cohort study analysing 106,212 patients with CVD between 2013 and 2019 reported an initial increase in CR participation from 28% in 2013 to 41% in 2016, after which rates stabilized [20]. Previously, RTW rates following CR have shown to be 65% at six months and 67% at twelve months following CR, with predictors including younger age, non-manual work, self-employment, higher quality of life, and favourable exercise ECG outcomes [21]. Although one Danish study indicated a lower probability of RTW at three months following CR, it demonstrated a higher probability at nine and twelve months [22]. In the Netherlands, CR programs are multidisciplinary, comprising exercise training, cardiovascular risk management, psychological support, and occupational counselling, aligned with national and European guidelines. Regarding neurorehabilitation, 86% of patients with acquired brain injury returned to work immediately after a four-month vocational rehabilitation program, with 64% remaining employed at long-term follow-up [23]. Dutch neurorehabilitation similarly integrates physical, cognitive, psychological, and vocational interventions to enhance functional recovery and work reintegration. Interestingly, Yokota et al. demonstrated in a small study population that cardiac rehabilitation following standardized in-hospital rehabilitation improved exercise tolerance and functional strength in patients recovering from cerebrovascular stroke [24].

This study, based on a day-to-day occupational healthcare database covering approximately 28% of Dutch employees with absenteeism, likely underestimates the true prevalence and impact of CVD due to delayed diagnosis registration, single-code recording, and overlap with mental health conditions. Extrapolation to the full workforce and to other countries requires caution given systemic differences. Additionally, absenteeism duration was censored for part of the cohort, presenteeism was not assessed, and the friction cost method used may underestimate the true economic burden, suggesting the actual impact of CVD is greater than reported. See the ESMfor a more detailed description of the limitations.