Financial incentives to promote cardiac rehabilitation participation and adherence among Medicaid patients

Improving Cardiac Rehabilitation Adherence in Patients With Lower Socioeconomic Status: A Randomized Clinical Trial

Importance

Participation in cardiac rehabilitation is associated with significant decreases in morbidity and mortality. Despite the proven benefits, cardiac rehabilitation is severely underutilized in certain populations, specifically those with lower socioeconomic status (SES).

Objective

To assess the efficacy of early case management and/or financial incentives for increasing cardiac rehabilitation adherence among patients with lower SES.

Design, Setting, and Participants

This randomized clinical trial enrolled patients from December 2018 to December 2022. Participants were followed up for 1 year with assessors and cardiac rehabilitation staff blinded to study condition. Patients with lower SES with a cardiac rehabilitation-qualifying diagnosis (myocardial infarction, coronary artery bypass graft, percutaneous coronary intervention, heart valve replacement/repair, or stable systolic heart failure) were recruited. Then patients attended one of 3 cardiac rehabilitation programs at 1 university or 2 community-based hospitals. A consecutively recruited sample was randomized and stratified by age (<57 vs ≥57 years) and smoking status (current smoker vs nonsmoker or former smoker).

Intervention

Participants were randomized 2:3:3:3 to either a usual care control, case management starting in-hospital, financial incentives for completing cardiac rehabilitation sessions, or both interventions (case management plus financial incentives). Interventions were in place for 4 months following informed consent.

Main Outcomes and Measures

The main outcome was cardiac rehabilitation adherence (proportion of patients completing ≥30 sessions). The a priori hypothesis was that interventions would improve adherence, with the combined intervention performing best.

Results

Of 314 individuals approached, 11 were ineligible, and 94 declined participation. Of the 209 individuals who were randomized, 17 were withdrawn. A total of 192 individuals (67 [35%] female; mean [SD] age, 58 [11] years) were included in the analysis. Interventions significantly improved cardiac rehabilitation adherence with 4 of 36 (11%), 13 of 51 (25%), 22 of 53 (42%), and 32 of 52 (62%) participants completing at least 30 sessions in the usual care, case management, financial incentives, and case management plus financial incentives conditions, respectively. The financial incentives and case management plus financial incentives conditions significantly improved cardiac rehabilitation adherence vs usual care (adjusted odds ratio [AOR], 5.1 [95% CI, 1.5-16.7]; P = .01; AOR, 13.2 [95% CI, 4.0-43.5]; P < .001, respectively), and the case management plus financial incentives condition was superior to both case management or financial incentives alone (AOR, 5.0 [95% CI, 2.1-11.9]; P < .001; AOR, 2.6 [95% CI, 1.2-5.9]; P = .02, respectively). Interventions were received well by participants: 86 of 105 (82%) in the financial incentives conditions earned at least some incentives, and 96 of 103 participants (93%) assigned to a case manager completed the initial needs assessment.

Conclusion and Relevance

In this randomized clinical trial, financial incentives improved cardiac rehabilitation adherence in a population with higher risk and lower SES with additional benefit from adding case management.

Trial Registration

ClinicalTrials.gov Identifier: NCT03759873.

Lower-Socioeconomic Status Patients Have Extremely High-Risk Factor Profiles on Entry to Cardiac Rehabilitation

PURPOSE

Patients with lower socioeconomic status (SES) have higher rates of cardiovascular events, yet are less likely to engage in secondary prevention such as cardiac rehabilitation (CR). Given the low number of lower-SES patients entering CR, characterization of this population has been difficult. Our CR program specifically increased recruitment of lower-SES patients, allowing for careful comparison of medical, psychosocial, and behavioral risk factors between lower- and higher-SES patients eligible for secondary prevention.

METHODS

Demographic and clinical characteristics were prospectively gathered on consecutive individuals entering phase 2 CR from January 2014 to December 2022. Patients were classified as lower SES if they had Medicaid insurance. Statistical methods included chi-square and nonpaired t tests. A P value of <.01 was used to determine significance.

RESULTS

The entire cohort consisted of 3131 individuals. Compared with higher-SES patients, lower-SES individuals (n = 405; 13%) were a decade younger (57.1 ± 10.4 vs 67.2 ± 11.2 yr), 5.8 times more likely to be current smokers (29 vs 5%), 1.7 times more likely to have elevated depressive symptoms, and significantly higher body mass index, waist circumference, and glycated hemoglobin A 1c , with more abnormal lipid profiles (all P s < .001). Despite being a decade younger, lower-SES patients had lower measures of cardiorespiratory fitness and self-reported physical function (both P s < .001).

CONCLUSION

Lower-SES patients have a remarkably prominent high-risk cardiovascular disease profile, resulting in a substantially higher risk for a recurrent coronary event than higher-SES patients. Accordingly, efforts must be made to engage this high-risk population in CR. It is incumbent on CR programs to ensure that they are appropriately equipped to intervene on modifiable risk factors such as low cardiorespiratory fitness, obesity, depression, and smoking.

Self-Reported Executive Function in Hospitalized Cardiac Patients and Associations With Patient Characteristics and Cardiac Rehabilitation Attendance

PURPOSE

Executive function (ExF), the ability to do complex cognitive tasks like planning and refraining from impulsive behavior, is associated with compliance with medical recommendations. The present study identified associations between self-reported ExF and demographics of patients with cardiac disease as well as with cardiac rehabilitation (CR) attendance.

METHODS

Self-reported ExF impairment was measured using the Behavior Rating Inventory of Executive Function (BRIEF) on 316 individuals hospitalized for CR-qualifying cardiac events. Scores were calculated for a global measure (Global Executive Composite [GEC]) and the two BRIEF indices: Behavioral Regulation Index and Metacognition Index (MCI). Participants were followed up post-discharge to determine CR attendance. Univariate logistic regressions between ExF measures and demographic variables were conducted, as were multiple logistic regressions to identify significant, independent predictors. Analyses were conducted using clinical (T scores ≥ 65) and subclinical (T scores ≥ 60) criteria for significant ExF impairment as outcomes. One-way analyses of variance were performed between ExF impairment and CR attendance.

RESULTS

Self-reported ExF deficits were relatively rare; 8.9% had at least subclinical scores on the GEC. Using the subclinical criterion for the MCI, having diabetes mellitus (DM) and being male were significant, independent predictors of MCI impairment. No significant relationship was found between ExF and CR attendance.

CONCLUSION

Using the subclinical criterion only, individuals with DM and males were significantly more likely to have MCI impairment. No significant effect of ExF impairment on CR attendance was found, suggesting that self-reported ExF measured in the hospital may not be an appropriate measure for predicting behavioral outcomes.

Encouraging adherence in adolescents with asthma using financial incentives: An RCT

BACKGROUND

Medication adherence in adolescents remains a significant management challenge and innovative strategies are needed to improve medication adherence. Financial incentives have been used to improve outcomes for health behaviors among adults, but have not been well-studied among adolescents. The objective of this study was to test if a modest financial incentive improved medication adherence in adolescents with asthma compared with a control group.

METHODS

Participants were randomized to either control (electronic medication monitoring [EMM] with App reminders/feedback for 4 months) or intervention (EMM + $1 per day for perfect medication adherence for 3 months [maximum $84] followed by 1 month of EMM only). A repeated measures mixed model, with a first order autoregressive correlation structure between errors, was used to test the null hypothesis for an interaction of treatment group and week.

RESULTS

Fifty-two participants were enrolled, and 48 completed primary analysis. Mean adherence rates declined in both groups over time, and there was no significant difference in the change in adherence rates between the groups (F-statistic = 0.72, ndf = 15, ddf = 625, p = 0.76). Adherence rates (during the 12 weeks when incentives were given) declined from 80% to 64% in the control group, and from 90% to 58% in the incentive group. There was no significant change in the slope of decline in the incentives group in the month following payment discontinuation.

CONCLUSION

A modest financial incentive did not lead to significantly different medication adherence rates in adolescents with asthma who were receiving a monitoring and reminder intervention. Further study is needed to determine viable interventions to optimize medication use in this group.

A New Era in Cardiac Rehabilitation Delivery: Research Gaps, Questions, Strategies, and Priorities

Cardiac rehabilitation (CR) is a guideline-recommended, multidisciplinary program of exercise training, risk factor management, and psychosocial counseling for people with cardiovascular disease (CVD) that is beneficial but underused and with substantial disparities in referral, access, and participation. The emergence of new virtual and remote delivery models has the potential to improve access to and participation in CR and ultimately improve outcomes for people with CVD. Although data suggest that new delivery models for CR have safety and efficacy similar to traditional in-person CR, questions remain regarding which participants are most likely to benefit from these models, how and where such programs should be delivered, and their effect on outcomes in diverse populations. In this review, we describe important gaps in evidence, identify relevant research questions, and propose strategies for addressing them. We highlight 4 research priorities: (1) including diverse populations in all CR research; (2) leveraging implementation methodologies to enhance equitable delivery of CR; (3) clarifying which populations are most likely to benefit from virtual and remote CR; and (4) comparing traditional in-person CR with virtual and remote CR in diverse populations using multicenter studies of important clinical, psychosocial, and cost-effectiveness outcomes that are relevant to patients, caregivers, providers, health systems, and payors. By framing these important questions, we hope to advance toward a goal of delivering high-quality CR to as many people as possible to improve outcomes in those with CVD.

Improving cardiac rehabilitation patient adherence via personalized interventions

Objectives

Despite documented benefits and physicians’ recommendations to participate in cardiac rehabilitation (CR) programs, the average dropout rate remains between 12–56%. This study’s goal was to demonstrate that using personalized interventions can significantly increase patient adherence.

Method

Ninety-five patients (ages 18–90) eligible for the CR program were randomly recruited and received personalized interventions using the Well-Beat system. Adherence levels were compared to those of a historical control group. The Well-Beat system provided Sheba CR Health Care Provider (HCP) guidelines for personalized patient-therapist dialogue. The system also generated ongoing personalized text messages for each patient sent twice a week and related each patient’s dynamic profile to their daily behavior, creating continuity, and reinforcing the desired behavior.

Results

A significant increase in patient adherence to the CR program: Three months after initiation, 76% remained active compared to the historical average of 24% in the matched control group (log-rank p-value = 0.001).

Conclusions

Using an Artificial Intelligence (AI)-based engine that generated recommendations and messages made it possible to improve patient adherence without increasing HCP load, benefiting all. Presenting customized patient insights to the HCP and generating personalized communications along with action motivating text messages can also be useful for remote care.

The Association of Patient Educational Attainment With Cardiac Rehabilitation Adherence and Health Outcomes

PURPOSE

Participating in cardiac rehabilitation (CR) after a cardiac event provides many clinical benefits. Patients of lower socioeconomic status (SES) are less likely to attend CR. It is unclear whether they attain similar clinical benefits as patients with higher SES. This study examines how educational attainment (one measure of SES) predicts both adherence to and improvements during CR.

METHODS

This was a prospective observational study of 1407 patients enrolled between January 2016 and December 2019 in a CR program located in Burlington, VT. Years of education, smoking status (self-reported and objectively measured), depression symptom level (Patient Health Questionnaire), self-reported physical function (Medical Outcomes Survey), level of fitness (peak metabolic equivalent, peak oxygen uptake, and handgrip strength), and body composition (body mass index and waist circumference) were obtained at entry to, and for a subset (n = 917), at exit from CR. Associations of educational attainment with baseline characteristics were examined using Kruskal-Wallis or Pearson's χ 2 tests as appropriate. Associations of educational attainment with improvements during CR were examined using analysis of covariance or logistic regression as appropriate.

RESULTS

Educational attainment was significantly associated with most patient characteristics examined at intake and was a significant predictor of the number of CR sessions completed. Lower educational attainment was associated with less improvement in cardiorespiratory fitness, even when controlling for other variables.

CONCLUSIONS

Patients with lower SES attend fewer sessions of CR than their higher SES counterparts and may not attain the same level of benefit from attending. Programs need to increase attendance within this population and consider program modifications that further support behavioral changes during CR.

A Structured Review of Commercially Available Cardiac Rehabilitation mHealth Applications Using the Mobile Application Rating Scale

PURPOSE

This study systematically evaluated the quality and functionalities of patient-facing, commercially available mobile health (mHealth) apps for cardiac rehabilitation (CR).

METHODS

We performed our search in two of the most widely used commercial mobile app stores: Apple iTunes Appstore and Google Play Store (Android apps). Six search terms were used to query relevant CR apps: "cardiac rehabilitation," "heart disease and remote therapy," "heart failure exercise," "heart therapy and cardiac recovery," "cardiac recovery," and "heart therapy." App quality was evaluated using the Mobile Application Rating Scale (MARS). App functionality was evaluated using the IQVIA functionality scale, and app content was evaluated against the American Heart Association guidelines for CR. Apps meeting our inclusion criteria were downloaded and evaluated by two to three reviewers, and interclass correlations between reviewers were calculated.

RESULTS

We reviewed 3121 apps and nine apps met our inclusion criteria. On average, the apps scored a 3.0 on the MARS (5-point Likert scale) for overall quality. The two top-ranking mHealth apps for CR for all three quality, functionality, and consistency with evidence-based guidelines were My Cardiac Coach and Love My Heart for Women, both of which scored ≥4.0 for behavior change.

CONCLUSION

Overall, the quality and functionality of free apps for mobile CR was high, with two apps performing the best across all three quality categories. High-quality CR apps are available that can expand access to CR for patients with cardiovascular disease.

Motivational Strategies and Concepts to Increase Participation and Adherence in Cardiac Rehabilitation: AN INTEGRATIVE REVIEW

INTRODUCTION

Low participation and adherence to cardiac rehabilitation (CR) leads to ineffective care and increased risk of cardiac complications. There is a need to identify effective motivational strategies and concepts to increase participation and adherence to CR.

PURPOSE

The aim of this review was to synthesize and integrate the current knowledge about motivational strategies and concepts to increase participation and adherence to CR.

METHODS

A literature search was performed using five electronic databases: CINAHL, Medline via PubMed, Scopus, Embase, and Rehabilitation & Sports Medicine Source. The search was limited to peer-reviewed studies, written in English, and publications from 2010 to 2019. A matrix and narrative synthesis were employed to organize and synthesize the findings, respectively.

RESULTS

Eight of 522 articles met the inclusion criteria. Four articles used motivational interviewing (MotI) and counseling strategy, three articles investigated the autonomy, competence, and relatedness of self-determination theory (SDT) concepts, and one article used a reinforced motivational strategy. Use of MotI led to improving the CR completion rate from 14% to 39%. The number of sessions attended/patient improved from 12 to 20 when the staff was provided attendance feedback and a reward. Autonomy, competence, and relatedness motivated patients to participate in and adhere to CR.

CONCLUSIONS

Motivational interviewing and counseling, motivational and reinforcement strategies, and the autonomy, competence, and relatedness of SDT concepts should be utilized to promote participation and motivation for CR. The effects of these techniques on long-term CR require further research, including combining the identified methods to investigate the efficacy of these techniques on CR adherence.

Association of participation in Cardiac Rehabilitation with Social Vulnerability Index: The behavioral risk factor surveillance system

OBJECTIVES

To identify whether social vulnerability is associated with low cardiac rehabilitations (CR) use, a Class I recommendation by current treatment guidelines following acute myocardial infarction (AMI).

METHODS

We performed this cross-sectional study using the 2017 Behavioral Risk Factor Surveillance System (BRFSS) survey. The Centers for Disease Control and Prevention Social Vulnerability Index (CDC SVI) was calculated using 15 social risk factors from 4 main themes including socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. A higher SVI indicates higher social vulnerability. We used multivariable logistic regression models to evaluate the association of CR use with state-level SVI adjusted for demographic, behavioral, socioeconomic, and comorbidity variables.

RESULTS

A total 2093 participants with history of AMI were included. Out of total, 61.7% were older than 65 years, 42.5% female, 72.5% White, and 42.4% used CR. Participation in CR was lower among females (odds ratio [OR], 0.64; 95% confidence interval [CI], 0.44-0.91), those without a primary care physician (OR, 0.45; 95% CI, 0.23-0.87), and higher with college degree education (OR, 1.95; 95% CI, 1.06-3.59). CR use decreased with increasing SVI tertiles (1st =61%, 2nd =52%, and 3rd =35%). Compared with those residing in states in the 1st tertile, CR use was lower in the 2nd (OR, 0.68; 95% CI, 0.47-0.98) and 3rd (OR, 0.33; 95% CI 0.23-0.48) SVI tertiles.

CONCLUSION

CR use following AMI is low and is associated with social vulnerability. Identifying social risk factors may help improve access to care among vulnerable populations.

Enhancing participation in cardiac rehabilitation: Focus on underserved populations

Participation in cardiac rehabilitation (CR) significantly decreases morbidity and mortality and improves quality of life following a wide variety of cardiac diagnoses and interventions. However, participation rates and adherence with CR are still suboptimal and certain populations, such as women, minorities, and those of lower socio-economic status, are particularly unlikely to engage in and complete CR. In this paper we review the current status of CR participation rates and interventions that have been used successfully to improve CR participation. In addition, we review populations known to be less likely to engage in CR, and interventions that have been used to improve participation specifically in these underrepresented populations. Finally, we will explore how CR programs may need to expand or change to serve a greater proportion of CR-eligible populations. The best studied interventions that have successfully increased CR participation include automated referral to CR and utilization of a CR liaison person to coordinate the sometimes awkward transition from inpatient status to outpatient CR participation. Furthermore, it appears likely that maximizing secondary prevention in these at-risk populations will require a combination of increasing attendance at traditional center-based CR programs among underrepresented populations, improving and expanding upon tele- or community-based programs, and alternative strategies for improving secondary prevention in those who do not participate in CR.

Association Between Increased Hospital Reimbursement for Cardiac Rehabilitation and Utilization of Cardiac Rehabilitation by Medicare Beneficiaries: An Interrupted Time Series

BACKGROUND

Although cardiac rehabilitation (CR) is a Class I Guideline recommendation, and has been shown to be a cost-effective intervention after a cardiac event, it has been reimbursed at levels insufficient to cover hospital operating costs. In January 2011, Medicare increased payment for CR in hospital outpatient settings by ≈180%. We evaluated the association between this payment increase and participation in CR of eligible Medicare beneficiaries to better understand the relationship between reimbursement policy and CR utilization.

METHODS

From a 5% Medicare claims sample, we identified patients with acute myocardial infarction, coronary artery bypass surgery, percutaneous coronary intervention, or cardiac valve surgery between January 1, 2009 and September 30, 2012, alive 30 days after their event, with continuous enrollment in Medicare fee-for-service, Part A/B for 4 months. Trends and changes in CR participation were estimated using an interrupted time series approach with a hierarchical logistic model, hospital random intercepts, adjusted for patient, hospital, market, and seasonality factors. Estimates were expressed using average marginal effects on a percent scale.

RESULTS

Among 76 695 eligible patients, average annual CR participation was 19.5% overall. In the period before payment increase, adjusted annual participation grew by 1.1 percentage points (95% CI, 0.48-2.4). No immediate change occurred in CR participation when the new payment was implemented. In the period after payment increase, on average, 20% of patients participated in CR annually. The annual growth rate in CR participation slowed in the post-period by 1.3 percentage points (95% CI, -2.4 to -0.12) compared with the prior period. Results were somewhat sensitive to time window variations.

CONCLUSIONS

The 2011 increase in Medicare reimbursement for CR was not associated with an increase in participation. Future studies should evaluate whether payment did not reach a threshold to incentivize hospitals or if hospitals were not sensitive to reimbursement changes.

Quality indicators for cardiac rehabilitation after myocardial infarction in China: a consensus panel and practice test

OBJECTIVES

Cardiac rehabilitation (CR) improves outcomes after myocardial infarction (MI), but it is underused in China. The purpose of this study was to develop a set of quality indicators (QIs) to improve clinical practices and to confirm the measurability and performance of the developed QIs for CR in Chinese patients after MI.

DESIGN AND SETTING

The QIs were developed by a Chinese expert consensus panel during in-person meetings. The five QIs most in need of improvement were selected using a national questionnaire. Finally, the completion rate and feasibility of the QIs were verified in a group of MI survivors at university hospitals in China.

PARTICIPANTS

Seventeen professionals participated in the consensus panel, 89 personnel in the field of CR participated in the national questionnaire and 165 MI survivors participated in the practice test.

RESULTS

A review of 17 eligible articles generated 26 potential QIs, among which 17 were selected by the consensus panel after careful evaluation. The 17 QIs were divided into two domains: (1) improving participation and adherence and (2) CR process standardisation. Nationwide telephone and WeChat surveys identified the five QIs most in need of improvement. A multicenter practice test (n=165) revealed that the mean performance value of the proposed QIs was 43.9% (9.9%-86.1%) according to patients with post-MI.

CONCLUSIONS

The consensus panel identified a comprehensive set of QIs for CR in patients with post-MI. A nationwide questionnaire survey was used to identify the QIs that need immediate attention to improve the quality of CR. Although practice tests confirmed the measurability of the proposed QIs in clinical practice, the implementation of the QIs needs to be improved.

TRIAL REGISTRATION NUMBER

This study is part of a study registered in ClinicalTrials.gov (NCT03528382).

Higher Anxiety and Will to Live Are Associated With Poorer Adherence to Cardiac Rehabilitation

PURPOSE

Cardiac rehabilitation (CR) session attendance and rates of completion remain suboptimal. Greater distress (ie, depression and anxiety) has been associated with both better and poorer adherence. Will to live (ie, desire, determination and effort to survive) has been associated with survival among cardiac patients and thus may be relevant for CR adherence. It was hypothesized that depression and anxiety would be negatively associated with adherence, and that will to live would moderate these relationships.

METHODS

Sixty patients (mean age = 56.9 ± 10.8 yr; 38 males) entering outpatient CR completed self-report measures of will to live (Wish to Prolong Life Questionnaire) and distress (Hospital Anxiety and Depression Scale). Hierarchical regression analyses were performed to predict CR session attendance (%) and program completion (yes/no) from depression and anxiety, as well as the interaction of those variables with will to live.

RESULTS

Neither depression nor anxiety was associated with CR adherence (Ps > .33). However, there was a significant interaction of will to live with anxiety in predicting attendance (β= -0.31, P = .03, Model R = .19, P = .01), reflecting that anxiety predicted lower attendance only among patients reporting greater will to live.

CONCLUSIONS

These data help clarify the complex relationship between distress and CR adherence. Findings suggest that higher anxiety is associated with poorer adherence, but only in combination with greater motivation for living. Patients higher in anxiety and will to live may benefit from additional strategies to make actionable behavioral change in the context of CR.

Behavior-Analytic Approaches to the Management of Diabetes Mellitus: Current Status and Future Directions

Diabetes mellitus is the seventh leading cause of death in the United States, requiring a series of complex behavior changes that must be sustained for a lifetime (e.g., counting carbohydrates, self-monitoring blood glucose, adjusting insulin). Although complex, all of these tasks involve behavior, making them amenable targets for behavior analysts. In this article, the authors describe interventions that have focused on antecedent, consequent, multicomponent, and alternate procedures for the management of diabetes, highlighting ways in which technology has been used to overcome common barriers to the use of these intensive, evidence-based interventions. Additional variables relevant to poorly managed diabetes (e.g., delay discounting) are also discussed. Future research and practice should focus on harnessing continued advances in information technology while also considering underexplored behavioral technologies for the effective treatment of diabetes, with a focus on identifying sustainable, long-term solutions for maintaining proper diabetes management. Practical implementation of these interventions will depend on having qualified behavior analysts working in integrated primary care settings where the interventions are most likely to be used, which will require interdisciplinary training and collaboration.

Increasing Use of Cardiac and Pulmonary Rehabilitation in Traditional and Community Settings: OPPORTUNITIES TO REDUCE HEALTH CARE DISPARITIES

Although both cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) are recommended by clinical practice guidelines and covered by most insurers, they remain severely underutilized. To address this problem, the National Heart, Lung, and Blood Institute (NHLBI), in collaboration with the National Institute on Aging (NIA), developed Funding Opportunity Announcements (FOAs) in late 2017 to support phase II clinical trials to increase the uptake of CR and PR in traditional and community settings. The objectives of these FOAs were to (1) test strategies that will lead to increased use of CR and PR in the US population who are eligible based on clinical guidelines; (2) test strategies to reduce disparities in the use of CR and PR based on age, gender, race/ethnicity, and socioeconomic status; and (3) test whether increased use of CR and PR, whether by traditional center-based or new models, is accompanied by improvements in relevant clinical and patient-centered outcomes, including exercise capacity, cardiovascular and pulmonary risk factors, and quality of life. Five NHLBI grants and a single NIA grant were funded in the summer of 2018 for this CR/PR collaborative initiative. A brief description of the research to be developed in each grant is provided.

Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers

INTRODUCTION

Cardiac rehabilitation (CR) significantly reduces secondary cardiovascular events and mortality and is a class 1A recommendation by the American Heart Association (AHA) and American College of Cardiology (ACC). However, it remains an underutilized intervention and many eligible patients fail to enroll or complete CR programs. The aim of this review is to identify barriers to CR attendance and discuss strategies to overcome them.

AREAS COVERED

Specific barriers to CR attendance and participation will be reviewed. This will be followed by a discussion of solutions/strategies to help overcome these barriers with a particular focus on home-based CR (HBCR).

EXPERT OPINION

HBCR alone or in combination with center-based CR (CBCR) can help overcome many barriers to traditional CBCR participation, such as schedule flexibility, time commitment, travel distance, cost, and patient preference. Using remote coaching with indirect exercise supervision, HBCR has been shown to have comparable benefits to CBCR. At this time, however, funding remains the main barrier to universal incorporation of HBCR into health systems, necessitating the need for additional cost benefit analysis and outcome studies. Ultimately, the choice for HBCR should be based on patient preference and availability of resources.

Inhibitory-control training for cocaine use disorder and contingency management for clinic attendance: A randomized pilot study of feasibility, acceptability and initial efficacy

BACKGROUND

Cocaine abusers have impaired inhibitory Cocaine use is associated with impaired inhibitory control. This study determined the feasibility, acceptability, and initial efficacy of inhibitory-control training to cocaine or neutral images in cocaine use disorder patients.

METHODS

Participants were randomly assigned to inhibitory-control training to cocaine (N = 20) or neutral (N = 20) images. Feasibility was assessed by percent of patients eligible for participation after a behavioral qualification session, time-to-target enrollment, percent of clinic visits attended, percent of participants who completed 80 % or more training sessions, and percent of follow-up visits attended. Acceptability was determined using a Treatment Acceptability Questionnaire. Initial efficacy was determined during training and a follow-up phase with urine samples tested qualitatively and quantitatively for cocaine. Participants in both conditions received monetary incentives delivered on an escalating schedule for clinic attendance.

RESULTS

The groups were well matched and no differences on demographic or substance use variables were observed. Attendance was stable during the treatment period with high overall attendance in both groups (average sessions attended: cocaine image group = 97 %; neutral image group = 90 %). No group differences were observed in the percentage of follow-up sessions attended (95 % for the cocaine-image group; 88 % of neutral-image group). Ratings on the Treatment Acceptability Questionnaire were high (i.e., mean scores ≥ 80 for all items rated on 101-unit visual analog scales). Participants in the cocaine- and neutral-image conditions did not differ significantly in terms of cocaine use during the training nor follow-up phase. Inhibitory-control training improved stop signal performance but not delay discounting.

CONCLUSION

The procedures were feasible and acceptable. Inhibitory-control training to cocaine images did not reduce cocaine use relative to the neutral image training condition. The inability to detect significant differences in cocaine use across the groups is not surprising given the small sample size. More research is needed to determine the utility of inhibitory-control training for cocaine use disorder. Future trials should determine whether inhibitory-control training to cocaine images augments the efficacy of other behavioral interventions.

Cardiac rehabilitation in older adults: New options

Cardiac rehabilitation (CR) is an important component in the continuum of care for patients with cardiovascular diseases, including the older population. Benefits of CR which include mortality benefit, decreased hospitalizations, increased functional capacity all extend to an older population. In Medicare beneficiaries which represent an older population, utilization of CR continues to remain low despite evidence that suggests lower hospitalization rates, Medicare costs, and improved symptoms. Given poor referral rates, enrollment rates, and completion rates, a call for new strategies has been made by all major societies. However, several barriers exist. Newer models of CR constructed to overcome these barriers are reviewed below. Some of these new strategies include alternative site CR or home‐based CR and the utilization of technology.

The effect of executive function on adherence with a cardiac secondary prevention program and its interaction with an incentive-based intervention

Participation in secondary prevention programs such as cardiac rehabilitation (CR) reduces morbidity, mortality, and hospitalizations while improving quality of life. Executive function (EF) is a complex set of cognitive abilities that control and regulate behavior. EF predicts many health-related behaviors, but how EF interacts with interventions to improve treatment adherence is not well understood. The objective of this study is to examine if EF predicts CR treatment adherence and how EF interacts with an intervention to improve adherence. Data were collected from 2013 to 2018 in Vermont, USA. 130 Medicaid-enrolled individuals who had experienced a qualifying cardiac event were enrolled in a controlled clinical trial and randomized 1:1 to receive financial incentives for completing secondary prevention sessions or to usual care. In this secondary analysis, effects of EF on CR adherence (defined as completing ≥30/36 sessions) were examined in 112 participants (57 usual care, 55 intervention) who completed an EF battery. Delay-discounting, a measure of impulsivity, predicted CR adherence (p = 0.01) and interacted with the incentive intervention, such that those who exhibited greater discounting of future rewards benefitted more from the intervention than those who discounted less (F(1, 104) = 5.23, p = 0.02). Better cognitive flexibility, measured with the trail-making-task, also predicted CR adherence (p = 0.02). While EF has been associated with adherence to a variety of treatment regimens, this interaction between an incentive-based intervention to promote treatment adherence and EF is novel. This work illustrates the value of considering individual differences in EF when designing and implementing interventions to promote health-related behavior change.

The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review

In this systematic literature review, we identify evidence on the effectiveness of nudges in improving the self-management of adults with chronic diseases and derive policy recommendations. We included empirical studies of any design published up to April 12^th, 2018. We synthesized the results of the studies narratively by comparing statistical significance and direction of different nudge types' effects on primary study outcomes. Lastly, we categorized the nudges according to their degree of manipulation and transparency. We identified 26 studies, where 13 were of high or moderate quality. The most commonly tested nudges were reminders, planning prompts, small financial incentives, and feedback. Overall, 8 of 9 studies with a high or moderate quality ranking, focused on self-management outcomes, i.e., physical activity, attendance, self-monitoring, and medication adherence, found that nudges had significant positive effects. However, only 1 of 4 studies of high or moderate quality, analyzing disease control outcomes (e.g., glycemic control), found that nudges had a significant positive effect for one intervention arm. In summary, this review demonstrates that nudges can improve chronic disease self-management, but there is hardly any evidence to date that these interventions lead to improved disease control. Reminders, feedback, and planning prompts appear to improve chronic disease self-management most consistently and are among the least controversial types of nudges. Accordingly, they can generally be recommended to policymakers.

Cardiac Rehabilitation for Secondary Prevention of Cardiovascular Disease: 2019 Update

PURPOSE OF REVIEW

To provide updated information on the science and practice of cardiac rehabilitation (CR).

RECENT FINDINGS

Evidence continues to mount that supports the many benefits of CR as well as the important gap in delivering CR to all eligible patients. Recent studies have identified center-based and home-based strategies to improve the reach and impact of CR. Cardiac rehabilitation is a systematic, evidence-based approach to deliver effective secondary CVD preventive therapies to individuals with cardiovascular conditions. Because of a number of benefits that have been associated with CR, clinical practice guidelines strongly endorse CR services for eligible patients. Research supports CR as a high value service, with evidence of favorable clinical outcomes and costs. Unfortunately, a significant gap exists in CR participation due to a number of patient-, provider-, and system-level barriers. Solutions to most of these barriers have been identified and involve systematic approaches to CR delivery. The future is bright for CR as new strategies, new policies, and new methods of delivery continue to develop to help provide CR services to all eligible patients.

Voucher-Based Contingency Management is Efficacious but Underutilized in Treating Addictions

The United States lags far behind other industrialized countries on major markers of population health. Population health experts identify unhealthy behavior patterns (e.g., cigarette smoking, other substance use disorders, physical inactivity and poor food choices, nonadherence with recommended medical regimens) as the largest contributor to the status quo. Because these risk behaviors are overrepresented in socioeconomically disadvantaged and other vulnerable populations, they also increase health disparities. Hence, identifying evidence-based strategies to promote and sustain health-related behavior change is critical to improving U.S. population health. In this report, we review research demonstrating the efficacy of voucher-based contingency management delivered alone or in combination with other interventions for treating substance use disorders and other health-related behavior problems. The efficacy supporting these interventions is robust and discernible at the level of controlled randomized clinical trials and meta-analyses. Unfortunately, these evidence-based interventions are being underutilized in routine clinical care for substance use disorders, although they are used broadly in private-sector wellness programs and international programs to reduce chronic poverty. This report reviews the evidence supporting the efficacy of voucher-based contingency management using projects developed at the University of Vermont as exemplars and discusses dissemination of the model to public and private sector efforts to improve individual and population health.

Financial Incentives to Increase Cardiac Rehabilitation Participation Among Low-Socioeconomic Status Patients: A Randomized Clinical Trial

OBJECTIVES

This study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR).

BACKGROUND

Participation in CR reduces morbidity, mortality, and hospitalizations while improving quality of life. Lower-socioeconomic status (SES) patients are much less likely to attend and complete CR, despite being at increased risk for recurrent cardiovascular events.

METHODS

A total of 130 individuals enrolled in Medicaid with a CR-qualifying cardiac event were randomized 1:1 to receive financial incentives on an escalating schedule ($4 to $50) for completing CR sessions or to receive usual care. Primary outcomes were CR participation (number of sessions completed) and completion (≥30 sessions completed). Secondary outcomes included changes in sociocognitive measurements (depressive/anxious symptoms, executive function), body composition (waist circumference, body mass index), fitness (peak VO₂) over 4 months, and combined number of hospitalizations and emergency department (ED) contacts over 1 year.

RESULTS

Patients randomized to the incentive condition completed more sessions (22.4 vs. 14.7, respectively; p = 0.013) and were almost twice as likely to complete CR (55.4% vs. 29.2%, respectively; p = 0.002) as controls. Incentivized patients were also more likely to experience improvements in executive function (p < 0.001), although there were no significant effects on other secondary outcomes. Patients who completed ≥30 sessions had 47% fewer combined hospitalizations and ED visits (p = 0.014), as reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentive condition group (p = 0.079).

CONCLUSIONS

Financial incentives improve CR participation among lower-SES patients following a cardiac event. Increasing participation among lower-SES patients in CR is critical for positive longer-term health outcomes. (Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees; NCT02172820).

Interventions to promote patient utilisation of cardiac rehabilitation

BACKGROUND

International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation.

OBJECTIVES

First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations.

SEARCH METHODS

Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random-effects meta-regression for each outcome and explored prespecified study characteristics.

MAIN RESULTS

Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.Low-quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta-regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face-to-face; P = 0.01) were influential in increasing enrolment. Low-quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home-based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate-quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi-centre studies were less effective than those given in single-centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient studies to test for this in the other outcomes).With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women-tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment.

AUTHORS' CONCLUSIONS

Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face-to-face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion.

Ethnic minority members may be at risk for state hopelessness following hospitalization for ischemic heart disease

OBJECTIVE

To examine differences in state and trait hopelessness between ethnic minority and White patients hospitalized with ischemic heart disease (IHD).

METHODS

A descriptive cross-sectional design was used to enroll 517 patients at one Midwestern U.S. hospital. The State-Trait Hopelessness Scale measured hopelessness.

RESULTS

State hopelessness was higher in ethnic minority patients compared to Whites. Ethnic minority patients who had never been married had higher state hopelessness than those who were married or separated/divorced. There were no differences in trait hopelessness.

CONCLUSIONS

Ethnic minority patients with IHD, who have never been married, may be at higher risk for state hopelessness.

Pay-for-performance incentive program in a large dental group practice

BACKGROUND

Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance.

METHODS

The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics.

RESULTS

The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges.

CONCLUSIONS

This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address.

PRACTICAL IMPLICATIONS

Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.

Small Incentives Improve Weight Loss in Women From Disadvantaged Backgrounds

INTRODUCTION

Women from lower-income backgrounds have the highest rates of obesity. Thus, effective programs for this high-risk population are urgently needed. Evidence suggests that adding financial incentives to treatment helps to engage and promote health behavior change in lower-income populations; however, this has never been tested in women for obesity treatment. The purpose of this study was to examine whether adding small financial incentives to Internet weight loss treatment yields better weight loss outcomes in women from lower-income backgrounds compared with the same treatment without incentives. Weight losses in lower-versus higher-income women were also compared.

METHODS

Data were pooled from two randomized trials in which women (N=264) received either Internet behavioral weight loss treatment (IBWL) or IBWL plus incentives (IBWL+$). Weight was objectively assessed. Data were collected and analyzed from 2011 to 2017.

RESULTS

Women from lower-income backgrounds had significantly better weight loss outcomes in IBWL+$ compared with IBWL alone (6.4 [SD=4.9%] vs 2.6 [SD=4.6%], p=0.01). Moreover, a greater percentage achieved a ≥5% weight loss in IBWL+$ vs IBWL alone (52.6% vs 38.1%, p=0.01). Interestingly, the comparison between lower-income versus higher-income groups showed that, in IBWL alone, women with lower income achieved significantly poorer weight losses (3.4 [SD=4.2%] vs 4.9 [SD=4.0%], p=0.03). By contrast, in IBWL+$, weight loss outcomes did not differ by income status (5.0 [SD=5.6%] vs 5.3 [SD=3.8%], p=0.80), and a similar percentage of lower- versus higher-income women achieved a ≥5% weight loss (52.6% vs 53.8%, p=0.93).

CONCLUSIONS

An Internet behavioral weight loss program plus financial incentives may be an effective strategy to promote excellent weight losses in women with lower income, thereby enhancing equity in treatment outcomes in a vulnerable, high-risk population. These data also provide important evidence to support federally funded incentive initiatives for lower-income, underserved populations.

Trends and Predictors of Participation in Cardiac Rehabilitation Following Acute Myocardial Infarction: Data From the Behavioral Risk Factor Surveillance System

BACKGROUND

Participation in cardiac rehabilitation (CR) after acute myocardial infarction has been proven to significantly reduce morbidity and mortality. Historically, participation rates have been low, and although recent efforts have increased referral rates, current data on CR participation are limited.

METHODS AND RESULTS

Utilizing data from the Behavioral Risk Factor Surveillance System conducted by Centers for Disease Control and Prevention, we performed a population-based, cross-sectional analysis of CR post-acute myocardial infarction. Unadjusted participation from 2005 to 2015 was evaluated by univariable logistic regression. Multivariable logistic regression was performed with patient characteristic variables to determine adjusted trends and associations with participation in CR in more recent years from 2011 to 2015. Among the 32 792 survey respondents between 2005 and 2015, participation ranged from 35% in 2005 to 39% in 2009 (P=0.005) and from 38% in 2011 to 32% in 2015 (P=0.066). Between 2011 and 2015, participants were less likely to be female (odds ratio [OR] 0.763, 95% confidence interval [CI] 0.646-0.903), black (OR 0.700, 95% CI 0.526-0.931), uninsured (OR 0.528, 95% CI 0.372-0.751), less educated (OR 0.471, 95% CI 0.367-0.605), current smokers (OR 0.758, 95% CI 0.576-0.999), and were more likely to be retired or self-employed (OR 1.393, 95% CI 1.124-1.726).

CONCLUSIONS

Only one third of patients participate in CR following acute myocardial infarction despite the known health benefits. Participants are less likely to be female, black, and uneducated. Future studies should focus on methods to maximize the proportion of CR referrals converted into CR participation.

Effect of Socioeconomic Status on Propensity to Change Risk Behaviors Following Myocardial Infarction: Implications for Healthy Lifestyle Medicine

Failure to change risk behaviors following myocardial infarction (MI) increases the likelihood of recurrent MI and death. Lower-socioeconomic status (SES) patients are more likely to engage in high-risk behaviors prior to MI. Less well known is whether propensity to change risk behaviors after MI also varies inversely with SES. We performed a systematized literature review addressing changes in risk behaviors following MI as a function of SES. 2160 abstracts were reviewed and 44 met eligibility criteria. Behaviors included smoking cessation, cardiac rehabilitation (CR), medication adherence, diet, and physical activity (PA). For each behavior, lower-SES patients were less likely to change after MI. Overall, lower-SES patients were 2 to 4 times less likely to make needed behavior changes (OR's 0.25-0.56). Lower-SES populations are less successful at changing risk behaviors post-MI. Increasing their participation in CR/secondary prevention programs, which address multiple risk behaviors, including increasing PA and exercise, should be a priority of healthy lifestyle medicine (HLM).

Financial Incentives for Reducing Smoking and Promoting Other Health-Related Behavior Change in Vulnerable Populations

Substantial reductions in U.S. cigarette smoking and associated chronic diseases over the past 50 years have benefited health. Unfortunately, those reductions have distributed unevenly throughout the population. Smoking remains prevalent and even increasing among certain vulnerable populations: economically disadvantaged groups, those with other substance-use disorders or mental illness, certain ethnic and racial minorities, and gender and sexual minorities. Moreover, other unhealthy behavior patterns (physical inactivity, unhealthy food choices, risky sexual behavior, poor adherence to medical preventive regimens) and associated chronic diseases are also overrepresented in many of these same populations. Disparities in unhealthy behavior patterns contribute to health disparities and escalating health care costs, underscoring the need for more effective behavior-change strategies. This report reviews research on the efficacy of financial incentives for reducing smoking in vulnerable populations, while also touching on applications of that behavior-change strategy for promoting other health-related behavior changes in vulnerable populations.

Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative

The primary aim of the Million Hearts initiative is to prevent 1 million cardiovascular events over 5 years. Concordant with the Million Hearts' focus on achieving more than 70% performance in the "ABCS" of aspirin for those at risk, blood pressure control, cholesterol management, and smoking cessation, we outline the cardiovascular events that would be prevented and a road map to achieve more than 70% participation in cardiac rehabilitation (CR)/secondary prevention programs by the year 2022. Cardiac rehabilitation is a class Ia recommendation of the American Heart Association and the American College of Cardiology after myocardial infarction or coronary revascularization, promotes the ABCS along with lifestyle counseling and exercise, and is associated with decreased total mortality, cardiac mortality, and rehospitalizations. However, current participation rates for CR in the United States generally range from only 20% to 30%. This road map focuses on interventions, such as electronic medical record-based prompts and staffing liaisons that increase referrals of appropriate patients to CR, increase enrollment of appropriate individuals into CR, and increase adherence to longer-term CR. We also calculate that increasing CR participation from 20% to 70% would save 25,000 lives and prevent 180,000 hospitalizations annually in the United States.