Participation in outpatient cardiac rehabilitation (CR) decreases morbidity and mortality for patients hospitalized with myocardial infarction, coronary bypass surgery or percutaneous revascularization. Unfortunately, only 10- 35% of patients for whom CR is indicated choose to participate. Lower socioeconomic status (SES) is a robust predictor of CR non-participation. There is growing recognition of the need to increase CR among economically disadvantaged patients, but there are almost no evidence-based interventions available for doing so. In the present study we are examining the efficacy of using early case management and financial incentives for increasing CR participation among lower-SES patients. Case management has been effective at promoting attendance at a variety of health-related programs (e.g. treatment for diabetes, HIV, asthma, cocaine dependence) as well as reducing hospitalizations. Financial incentives are also highly effective in altering health behaviors among disadvantaged populations (e.g., smoking during pregnancy, weight loss) including CR participation in our prior trial. For this study we will randomized 200 CR-eligible lower-SES patients to: a treatment condition where there are assigned a case manager while in hospital who will facilitate CR attendance and coordinate cardiac care, a treatment condition where they receive financial incentives contingent on initiation of and continued attendance at CR sessions, a combination of these two interventions, or to a ?usual-care? condition. Participants in all conditions will complete pre- and post-treatment assessments. Treatment conditions will be compared on attendance at CR and end-of-intervention improvements in fitness, executive function, and health-related quality of life. Cost effectiveness of the treatment conditions will also be examined by comparing the costs of delivering the interventions and the usual care condition taking into account increases in CR participation. Furthermore, we will model the value of the interventions based on increases in participation rates, intervention costs, long-term medical costs, and health outcomes after a coronary event. This systematic examination of promising interventions will allow us to test the efficacy and cost-effectiveness of approaches that have the potential to substantially increase CR participation and significantly improve health outcomes among lower-SES cardiac patients.
The proposed trial has the potential to make a substantive contribution to our understanding of the health and economic benefits of increasing cardiac rehabilitation participation in a vulnerable, underserved population of cardiac patients. The interventions have the potential to result in significant health gains and thereby also reduce health disparities in a population with historically abysmal cardiac participation rates who are also disproportionately at high risk for further health issues after their cardiac event.
