Case management, financial incentives may improve cardiac rehab adherence

Patients with lower socioeconomic status (SES) were more likely to attend cardiac rehab after hospitalization if they received support from a case manager and financial incentives, according to a recent study.

Researchers in Vermont performed a randomized controlled trial to assess whether early case management, financial incentives, or both would help increase adherence to cardiac rehab among patients with lower SES. From December 2018 to December 2022, patients were enrolled in the trial if they had a diagnosis that qualified them for cardiac rehab (i.e., myocardial infarction, coronary artery bypass graft, percutaneous coronary intervention, heart valve replacement/repair, or stable systolic heart failure) and were lower SES, defined as having Medicaid or less than a high school education. They were randomly assigned 2:3:3:3 to usual care, case management that started in the hospital, financial incentives for completing cardiac rehab sessions, or both interventions.

Patients in groups with financial incentives received $20 for orientation and incentives on an escalating scale for each completed cardiac rehab session, starting at $10 and increasing by $2 for each consecutive session attended for a maximum of $40 per session. Patients in groups with a case management intervention had an initial brief check-in, underwent an in-depth needs assessment, and had weekly calls with the case manager for 16 weeks, with phone support available as needed during normal working hours and Saturday mornings. Interventions continued for four months after patients provided informed consent. The study's main outcome measure was adherence to cardiac rehabilitation, defined as the proportion of patients completing at least 30 of 36 sessions. The results were published July 22 by JAMA Internal Medicine.

The analysis included 192 patients, 35% women, with a mean age of 58 years. Four of 36 patients (11%) in the usual care group, 13 of 51 (25%) in the case management group, 22 of 53 (42%) in the financial incentives group, and 32 of 52 (62%) in the case management plus financial incentives group completed at least 30 sessions. Both the financial incentives and case management plus financial incentives groups significantly improved adherence versus usual care (adjusted odds ratios [AOR], 5.1 [95% CI, 1.5 to 16.7] [P=0.01] and 13.2 [95% CI, 4.0 to 43.5] [P<0.001], respectively), while case management plus financial incentives was superior to case management or financial incentives alone (AORs, 5.0 [95% CI, 2.1 to 11.9] [P<0.001] and 2.6 [95% CI, 1.2 to 5.9] [P=0.02], respectively).

The researchers noted that their study was not designed to evaluate the effect of cardiac rehab on clinical outcomes and that it was conducted in only one state, among other limitations. “The results of this randomized clinical trial suggest that attendance at cardiac rehabilitation in populations with lower SES can be improved with intensive interventions,” they concluded. “Financial incentives alone, and in combination with case management, were successful at improving adherence to cardiac rehabilitation in this population.”

An accompanying editorial said the study emphasizes the importance of removing financial barriers to cardiac rehab and said that improving cardiac rehab referral, enrollment, and adherence is critical to reducing disparities in cardiovascular care and outcomes, particularly among those with lower SES and other groups.

“These patients experience a heterogenous set of barriers that requires a multifactorial and intersectional approach, and ... incentive payments from clinicians to patients can effectively improve CR [cardiac rehabilitation] adherence,” the editorialists wrote. “Although large-scale implementation of such a program would face challenges, other strategies by both clinicians and payers should be considered if we are to improve CR participation in patients with lower SES and other patient populations more broadly.”