研究背景：有關急性心肌梗塞（Acute Myocardial Infarction，AMI）的標準化發生率過去在2015年衛生福利部國民健康署的資料顯示年齡介於壯年時期（40-49歲）的患者，其發生率有增加的趨勢，代表生產力人口罹患急性心肌梗塞的比率可能提高，這將會是臺灣勞動市場的一大隱憂。過去文獻指出急性心肌梗塞後重返工作可能會受到社會人口學因素、身體及心理功能影響，並在國內、國外的一年內重返工作率差異可以從56%到93%。由於急性心肌梗塞對於臺灣勞動人口的影響層面很大，但過去文獻仍不足以解釋不同年齡、性別間對於工作軌跡變化的影響程度。然而，臺灣過去鮮少探討罹患急性心肌梗塞後工作軌跡變化的相關研究，需要更深入的再去探討那些決定因素可能會影響其工作軌跡變化。
研究目的：本研究藉由國家健保資料庫欲探討新罹患急性心肌梗塞對臺灣勞工的工作變動影響，並探討其影響因素，目的有下列兩點：首先，分析新發急性心肌梗塞勞工在發病月（T0）後第6、12、24及36個月之維持工作的比例，並探討影響因素。再來，計算個案各年累積工作月份，分析新發急性心肌梗塞勞工在發病月（T0）前2年到後3年間的工作軌跡種類，並探討影響因素。
研究方法：本研究設計採用回溯性世代研究，根據2011-2017年期間全民健康保險資料庫(住院醫療費用清單明細檔、門診處方及治療明細檔、承保檔及住院處方及治療醫令明細檔)、勞動部勞工保險資料庫(勞就保單位被保險人檔)、死因統計檔及戶籍檔資料，篩選個案為2013年1月1日至2014年12月31日期間，首次發生因急性心肌梗塞住院就醫之30至59歲勞工，定義急性心肌梗塞發生住院日為發病日，而工作變動分析所使用到工作狀態的起始點，定義皆為發病月（T0）並且往前後追蹤罹患急性心肌梗塞前後的工作變動情形。在評估急性心肌梗塞對於工作維持的趨勢時，採邏輯斯迴歸（Logistic regression）分析急性心肌梗塞患者間在發病月（T0）後工作有無的比例及其影響因素。透過群組化軌跡模型（Group-based trajectory modelling, GBTM），以累加每年工作月數作為依變項，分析發病月（T0）前後之工作軌跡種類。為確認影響急性心肌梗塞後工作軌跡變化的影響因素，多項邏輯斯迴歸（Multinominal logistic regression）用來分析軌跡分布比例與其影響因素的OR與95%CI。上述分析皆同時納入社會人口學變項、治療方式、共病情形進行校正。
研究結果：本研究之新發急性心肌梗塞個案共4,905人，而目標研究對象為具有勞工身分的新發個案，共2,659人。存活者之工作趨勢從T6的94.1%下降到T36的86.4%。透過邏輯斯迴歸發現，在T6、T12、T24、T36時，薪資≦19,999沒工作的風險分別是薪資>=60,000者的7.33倍、3.78倍、2.84倍及2.86倍。在T12、T24、T36時，50-59歲沒工作的風險分別是30-39歲者的1.93倍、2.55倍、2.63倍，CCI指數3分以上的個案沒工作的風險是無共病者的1.87倍、1.90倍及1.57倍。而相較於已婚者，T6、T12時間離婚、喪偶、婚姻消滅者沒工作的風險為1.57倍及1.54倍。教育程度、治療方式僅有部分時間出現差異。而經校正後，性別、都市化程度及教育程度統計上並無顯著差異。
AMI勞工發病後3年內皆存活者整體有2,371人，透過多項邏輯斯迴歸，在控制其他變項後，發現相較人數最多的A3維持工作組，未婚及離婚、喪偶、婚姻消滅此兩種特性分別有2.61倍及2.17倍的風險以及薪資≦19,999及20,000~39,999也分別有41.58倍及8.52倍風險成為A1快速失業組。由於不同年齡層的工作維持情形有差異，30-49歲工作軌跡發現相較人數最多的B3維持工作組，薪資≦19,999相對薪資>=60,000者有14.93倍風險成為B1快速失業組。最後，50-59歲工作軌跡分組同樣發現薪資≦19,999者有2.35倍風險，還有CCI共病3分以上相較於沒有共病者，有1.94倍風險成為C1失業組。
結論：研究結果證實臺灣存活者之工作比例在診斷後第3年（T36）有86.4%，於長期來說工作恢復情形還不錯，但是可以看到年齡較大、離婚、喪偶、婚姻消滅、薪資≦19,999及CCI分組3分以上等變項對於急性心肌梗塞發病後各追蹤期間無工作及工作軌跡有顯著影響性。尤其本研究又將工作軌跡分年齡層切分，發現薪資≦19,999、未婚及離婚、喪偶、婚姻消滅及CCI分組3分以上對於其工作軌跡組別區分具有影響性。根據上述，預期本研究能夠提供急性心肌梗塞後的工作維持政策方面更加完善。

Background: Past literature indicates that return to work within one year varies from 56% to 93% between domestic and foreign countries, and that return to work after acute myocardial infarction may be influenced by sociodemographic factors, physical and psychological factors. Since acute myocardial infarction has a large impact on Taiwan's labor force, the literature in the past is still insufficient to explain the degree of influence of different ages and genders on the changes in work trajectories. However, few studies in Taiwan have explored the changes in work trajectories after acute myocardial infarction, and more in-depth research is needed to explore those determinants that may affect the changes in their work trajectories.
Objectives: First, the proportion of new-onset acute myocardial infarction workers who maintained work at 6th, 12th, 24th, and 36th months after index month (To) was analyzed, and the influencing factors were explored. Second, the cumulative working months of each case were calculated, and the types of work trajectories of newly-onset acute myocardial infarction workers from the first 2 years to the 3 years after index month (To) were analyzed, and the influencing factors were discussed.
Methods: Cases were workers aged 30 to 59 years old who were hospitalized for acute myocardial infarction for the first time between January 1, 2013 and December 31, 2014. The hospitalization day for acute myocardial infarction was defined as index date, and work changes analysis used To as starting point of work status and defined as index month (To). When assessing the trend of acute myocardial infarction for work maintenance, logistic regression was used to analyze the proportion of acute myocardial infarction patients with or without work after index month (To) and its influencing factors. Through Group-based trajectory modelling (GBTM), with the cumulative number of working months per year as a dependent variable, the types of working trajectories before and after index month (To) were analyzed. Multinominal logistic regression was used to analyze the OR and 95% CI of the work proportion of trajectory distribution and its influencing factors. All analyses were adjusted for sociodemographic variables, treatment, and comorbidities.
Results: The total number of new acute myocardial infarction cases in our study was 4,905, and the target research object was 2,659 new cases with labor status. The work trend of survivors decreased from 94.1% for T6 to 86.4% for T36. Through logistic regression, it was found that at T6, T12, T24, and T36, the risk of not having a job with a salary of ≤ 19,999 was 7.33 times, 3.78 times, 2.84 times, and 2.86 times that of those with a salary >= 60,000, respectively. At T12, T24, and T36, the risk of 50-59-year-olds not working was 1.93 times, 2.55 times, and 2.63 times that of 30-39-year-olds, respectively. The risk of not working in cases with a CCI index of 3 or more was that of those without comorbidities. 1.87 times, 1.90 times and 1.57 times. Compared with married people, the risk of divorce, widowhood, and marriage extinction at T6 and T12 time was 1.57 times and 1.54 times higher than that of married people. Educational levels and treatment methods differed only part of the time. After adjustment, there were no significant differences in gender, urbanization and educational level. There were 2,371 survivors within 3 years after index month of AMI. Through multinominal logistic regression, after adjusting for variables, it was found that compared with the A3 maintenance work group with the largest number, unmarried and divorced, widowed, and marriage eliminated these two groups. The characteristics have 2.61 times and 2.17 times the risk respectively, and the salary ≤ 19,999 and 20,000~39,999 have 41.58 times and 8.52 times the risk of becoming the A1 rapid unemployment group respectively. Due to the differences in work maintenance situation of different age groups, the work trajectory of 30-49 years old found that compared with the B3 maintenance work group with the largest number of people, those with a salary of ≤ 19,999 and a relative salary of >= 60,000 had a 14.93 times risk of becoming the B1 rapid unemployment group. Finally, the 50-59-year-old work trajectory group also found that those with salary ≤ 19,999 had a 2.35-fold risk, and those with a CCI comorbidity score of 3 or more had a 1.94-fold risk of becoming the C1 unemployment group compared with those without comorbidities.
Conclusions: The results of our study confirmed that the employment rate of Taiwanese survivors was 86.4% in the third year (T36) after index month. In the long run, the work maintenance was not bad, but it could be seen that they were older, divorced, widowed, marital eliminated, salary ≤ 19,999 and CCI group score of 3 or more have significant influence on the absence of work and the track of work in each tracking period after index month of acute myocardial infarction. In particular, this study divides the work trajectories into age groups, and finds that salary ≤ 19,999, unmarried and divorced, widowed, marriage eliminated, and CCI grouping of more than 3 points have an impact on the distinction of their work trajectories. Based on the above, it is expected that this study can provide a more complete policy on work maintenance after acute myocardial infarction.

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