1
|
Gaalema DE, Khadanga S, Savage PD, Yant B, Katz BR, DeSarno M, Ades PA. Improving Cardiac Rehabilitation Adherence in Patients With Lower Socioeconomic Status: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:1095-1104. [PMID: 39037811 PMCID: PMC11264079 DOI: 10.1001/jamainternmed.2024.3338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/27/2024] [Indexed: 07/24/2024]
Abstract
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 Of the 209 individuals who were randomized, 17 were withdrawn.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.
Collapse
Affiliation(s)
- Diann E. Gaalema
- Department of Psychiatry, University of Vermont Larner College of Medicine, Burlington
- Department of Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston
| | - Sherrie Khadanga
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington
| | - Patrick D. Savage
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington
| | - Blair Yant
- Department of Psychiatry, University of Vermont Larner College of Medicine, Burlington
| | - Brian R. Katz
- Department of Psychiatry, University of Vermont Larner College of Medicine, Burlington
| | - Michael DeSarno
- Biomedical Statistics Research Core, University of Vermont, Burlington
| | - Philip A. Ades
- Department of Medicine, Division of Cardiology, University of Vermont, Burlington
| |
Collapse
|
2
|
Ghisi GLM, Bomtempo APD, Gonzalez NF, Reyes GP, Anchique CV. Evaluating the Clinical Effectiveness of Cardiac Rehabilitation among Patients of Very Low Socioeconomic Status Living in Colombia. J Cardiovasc Dev Dis 2024; 11:255. [PMID: 39330313 PMCID: PMC11432289 DOI: 10.3390/jcdd11090255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/19/2024] [Accepted: 08/20/2024] [Indexed: 09/28/2024] Open
Abstract
Cardiovascular disease (CVD) poses a significant health burden, particularly among individuals of low socioeconomic status (SES) in low- and middle-income countries (LMICs). This study evaluates the clinical effectiveness of cardiac rehabilitation (CR) in addressing CVD outcomes among very low-SES patients in Colombia. Data from participants enrolled in a CR program in Colombia between 2022 and 2023 were analyzed retrospectively. Measures included heart-healthy behaviors, physical/psychological outcomes, and quality of life assessed at 18, 36, and 60 sessions. Significant improvements were observed in exercise capacity, psychological well-being, and quality of life metrics throughout the CR program. However, barriers to CR attendance and the critical need for expanded program availability remain evident, particularly in LMIC settings like Colombia. In conclusion, structured CR programs demonstrate substantial benefits for very low-SES individuals in a LMIC country, highlighting the urgent need for increased program accessibility and equitable healthcare provision to optimize cardiovascular health outcomes.
Collapse
Affiliation(s)
- Gabriela L. M. Ghisi
- KITE Research Institute, University Health Network, University of Toronto, Toronto, ON M4G 1R7, Canada
| | - Ana Paula Delgado Bomtempo
- Graduate Program in Physical Education, Faculty of Physical Education and Sports, Federal University of Juiz de Fora, Juiz de Fora 36036-900, Brazil;
| | | | | | | |
Collapse
|
3
|
Middleton WA, Savage PD, Khadanga S, Rengo JL, Ades PA, Gaalema DE. Anxiety Predicts Worse Cardiorespiratory Fitness Outcomes in Cardiac Rehabilitation for Lower Socioeconomic Status Patients. J Cardiopulm Rehabil Prev 2024; 44:162-167. [PMID: 38300271 PMCID: PMC11065622 DOI: 10.1097/hcr.0000000000000852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
PURPOSE The purpose of this study was to show that patients in cardiac rehabilitation (CR) with lower socioeconomic status (SES) have worse clinical profiles and higher rates of psychiatric difficulties and they have lower cardiorespiratory fitness (CRF) improvements from CR than their counterparts with higher SES. Improvement in CRF during CR predicts better long-term health outcomes. Research suggests that higher anxiety impairs CRF in structured exercise regimes and is overrepresented among patients with lower SES. However, no study has determined whether this relationship holds true in CR. METHODS This study is a secondary analysis of a randomized controlled trial to improve CR attendance among patients with lower SES. Anxiety (ASEBA ASR; Achenbach System of Empirically Based Assessment, Adult Self Report) and CRF measures (metabolic equivalent tasks [METs peak ]) were collected prior to CR enrollment and 4 mo later. Regression was used to examine the association of anxiety with CRF at 4 mo while controlling for other demographic and clinical characteristics. RESULTS Eight-eight participants were included in the analyses, 31% of whom had clinically significant levels of anxiety ( T ≥ 63). Higher anxiety significantly predicted lower exit CRF when controlling for baseline CRF, age, sex, qualifying diagnosis, and number of CR sessions attended ( β =-.05, P = .04). Patients with clinically significant levels of anxiety could be expected to lose >0.65 METs peak in improvement. CONCLUSIONS The results from this study suggest that anxiety, which is overrepresented in populations with lower SES, is associated with less CRF improvement across the duration of CR. The effect size was clinically meaningful and calls for future research on addressing psychological factor in CR.
Collapse
Affiliation(s)
- William A Middleton
- Author Affiliations: Vermont Center on Behavior and Health (Mr Middleton and Drs Ades and Gaalema) and Departments of Psychiatry (Dr Gaalema) and Psychology (Mr Middleton and Dr Gaalema), The University of Vermont (Messrs Savage and Rengo and Drs Khadanga and Ades), Burlington; and Division of Cardiology, The University of Vermont College of Medicine, Burlington (Drs Khadanga and Ades)
| | | | | | | | | | | |
Collapse
|
4
|
Betancourt-Peña J, Portela-Pino I, Amaral-Figueroa M. Factors related to non-adherence to cardiac rehabilitation in patients with heart failure. Rev Clin Esp 2024; 224:24-33. [PMID: 38142975 DOI: 10.1016/j.rceng.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/26/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION In heart failure, cardiac rehabilitation has been recommended as an intervention strategy that improves functional capacity, health-related quality of life and survival. However, adherence to these programs is low. The objective was to determine the factors related to non-adherence to cardiac rehabilitation in patients with heart failure in Colombia. METHOD Observational and retrospective study. Patients with heart failure were linked in a clinic in Colombia, adherence to cardiac rehabilitation was measured with ≥80% of scheduled sessions. Sociodemographic and clinical variables, functional aerobic capacity (Sit to Stand and 6-minute walk test), Duke Activity Status Index (DASI), quality of life Minnesota Living with Heart Failure Questionnaire (MLFHQ) and depression Patient health questionnaire 9 (PHQ-9) were taken into account. RESULTS 300 patients were linked with heart failure with age 63.16 ± 12.87 men 194 (64.7%). adherence to cardiac rehabilitation was 66.67%, there were statistically significant differences between the groups in arterial hypertension, LVEF, cholesterol, LDL, Triglycerides, SBP, DBP, distance traveled, VO2e, METs, DASI and PHQ-9 p-value =<0.05. The logistic regression model adjusted for sex and age showed OR for non-adherence to CR arterial hypertension 2.23[1.22-4.07], LDL outside of goals 2.15[1.20-3.88], triglycerides outside goals 2.34[1.35-4.07], DASI<4METs 2.38 [1.04-5.45] and PHQ-9 1.06[1.00-1.12]. CONCLUSION High blood pressure, LDL, triglycerides, DASI and depression with the PHQ-9 questionnaire are related factors for not having adherence to cardiac rehabilitation in patients with heart failure.
Collapse
Affiliation(s)
- J Betancourt-Peña
- Facultad de Salud y Rehabilitación, Institución Universitaria Escuela Nacional del Deporte, Cali, Colombia; Facultad de Salud, Escuela de Rehabilitación Humana Universidad del Valle, Cali, Colombia; Universidad de Vigo, Vigo, Spain.
| | - I Portela-Pino
- Departamento de Ciencias de la Salud, Universidad Isabel I, Burgos, Castilla y León, Spain
| | - M Amaral-Figueroa
- Departamento de Educación Física y Recreación, Universidad de Puerto Rico-Recinto de Rio Piedras, San Juan, Puerto Rico
| |
Collapse
|
5
|
Irani S, Brandt EJ, Pai CW, Garfein J, Kline-Rogers E, Rubenfire M. Educational Attainment and Cardiovascular Risk Among Patients in Cardiac Rehabilitation. Am J Cardiol 2023; 207:465-469. [PMID: 37804557 DOI: 10.1016/j.amjcard.2023.08.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 10/09/2023]
Abstract
We explored whether patient educational attainment impacted changes in cardiovascular risk factors during cardiac rehabilitation (CR). An observational study was conducted using participant data who completed phase 2 of CR from January 2011 to February 2020 at an academic medical center. The patient cohort was referred to CR after a major cardiac event or to outpatients with stable angina. Patients were excluded if they had no recorded food frequency assessment (FFA) score at CR orientation and graduation. The eligible sample of 1,307 patients were further divided: (1) low educational attainment group (<16 years formal education: high school, high school/general educational development, trade school, and associate's degree) and (2) high educational attainment group (>16 years formal education: bachelor's degree, some postgraduate, master's degree, PhD, and MD). The outcomes included measurements of the FFA, body composition, biophysical health, and psychologic distress. Most patients were male (71.2%), non-Hispanic White (82.2%), and married (73.0%). There were more patients with a high educational attainment (56.8%) than patients with a low educational attainment (43.2%). All measured cardiovascular markers improved after CR for both education level groups. The change in mean FFA score (0.163, p = 0.11) and Brief Symptom Inventory-53 global severity index score (0.422, p = 0.34) did not differ significantly. We observed an improvement in cardiovascular risk measures upon CR participation. These improvements were not limited to high educational attainment patients because we found few differences in the change of risk between the 2 groups. Future studies should continue investigating the impact of education on cardiovascular outcomes as an important social determinant of health.
Collapse
Affiliation(s)
- Suzanne Irani
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Eric J Brandt
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Chih-Wen Pai
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Melvyn Rubenfire
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| |
Collapse
|
6
|
Filippini T, Malavolti M. Education and Disparities in Cardiac Rehabilitation Effectiveness. Am J Cardiol 2023; 207:499-500. [PMID: 37735059 DOI: 10.1016/j.amjcard.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Tommaso Filippini
- CREAGEN - Environmental, Genetic and Nutritional Epidemiology Research Center, Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Italy; School of Public Health, University of California Berkeley, Berkeley, California.
| | - Marcella Malavolti
- CREAGEN - Environmental, Genetic and Nutritional Epidemiology Research Center, Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Italy
| |
Collapse
|
7
|
Mansour AI, Fu W, Fliegner M, Stewart JW, Keteyian SJ, Thompson MP. Assessing the Readability and Quality of Cardiac Rehabilitation Program Websites in Michigan. J Cardiopulm Rehabil Prev 2023; 43:E23-E25. [PMID: 37643241 PMCID: PMC10615668 DOI: 10.1097/hcr.0000000000000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Alexandra I Mansour
- University of Michigan Medical School, Ann Arbor (Dr Mansour); Department of Surgery, Michigan Medicine, Ann Arbor (Drs Fu and Stewart); Oakland University William Beaumont School of Medicine, Auburn Hills, Michigan (Mr Fliegner); Division of Cardiovascular Medicine, Henry Ford Health, Detroit (Dr Keteyian); and Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, and Section of Health Services Research and Quality, Department of Cardiac Surgery, Michigan Medicine, Ann Arbor (Dr Thompson)
| | | | | | | | | | | |
Collapse
|
8
|
Yant B, Kromer L, Savage PD, Khadanga S, Ades PA, Gaalema DE. Financial incentives and case management to improve cardiac rehabilitation participation among patients with lower socio-economic status: Rationale and protocol for a randomized controlled trial. Contemp Clin Trials 2023; 129:107174. [PMID: 37019181 PMCID: PMC10225326 DOI: 10.1016/j.cct.2023.107174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Participation in phase 2 cardiac rehabilitation (CR) is associated with significant decreases in morbidity and mortality. Unfortunately, attendance at CR is not optimal and certain populations, such as those with lower-socioeconomic status (SES), are less likely to participate. In order to remedy this disparity we have designed a trial to examine the efficacy of early case management and/or financial incentives for increasing CR participation among lower-SES patients. METHODS We will employ a randomized controlled trial with a sample goal of 209 patients who will be randomized 2:3:3:3 to either a usual care control, to receive a case manager starting in-hospital, to receive financial incentives for completing CR sessions, or to receive both interventions. RESULTS Treatment conditions will be compared on attendance at CR and end-of-intervention (four months) improvements in cardiorespiratory fitness, executive function, and health-related quality of life. The primary outcome measures for this project will be number of CR sessions completed and the percentage who complete ≥30 sessions. Secondary outcomes will include improvements in health outcomes by condition, as well as the cost-effectiveness of the intervention with a focus on potential reductions in emergency department visits and hospitalizations. We hypothesize that either intervention will perform better than the control and that the combination of interventions will perform better than either alone. CONCLUSIONS This systematic examination of interventions will allow us to test the efficacy and cost-effectiveness of approaches that have the potential to increase CR participation substantially and significantly improve health outcomes among patients with lower-SES.
Collapse
Affiliation(s)
- Blair Yant
- University of Vermont, United States of America
| | - Lisa Kromer
- University of Vermont, United States of America
| | | | - Sherrie Khadanga
- University of Vermont, United States of America; University of Vermont Medical Center, United States of America
| | - Philip A Ades
- University of Vermont, United States of America; University of Vermont Medical Center, United States of America
| | | |
Collapse
|
9
|
Ades PA, Khadanga S, Savage PD, Gaalema DE. Enhancing participation in cardiac rehabilitation: Focus on underserved populations. Prog Cardiovasc Dis 2022; 70:102-110. [PMID: 35108567 PMCID: PMC9119375 DOI: 10.1016/j.pcad.2022.01.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 01/23/2022] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Philip A Ades
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America.
| | - Sherrie Khadanga
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
| | - Patrick D Savage
- Department of Medicine, Division of Cardiology, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
| | - Diann E Gaalema
- Department of Psychiatry, University of Vermont Larner College of Medicine, Cardiac Rehabilitation and Prevention, Burlington, VT, United States of America
| |
Collapse
|