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Association of Neighborhood Socioeconomic Context With Participation in Cardiac Rehabilitation.

ABSTRACT: BACKGROUND:Cardiac rehabilitation (CR) is underutilized in the United States, with fewer than 20% of eligible patients participating in CR programs. Individual socioeconomic status is associated with CR utilization, but data regarding neighborhood characteristics and CR are sparse. We investigated the association of neighborhood socioeconomic context with CR participation in the SCCS (Southern Community Cohort Study). METHODS AND RESULTS:The SCCS is a prospective cohort study of 84 569 adults in the southeastern United States from 2002 to 2009, 52 117 of whom have Medicare or Medicaid claims. Using these data, we identified participants with hospitalizations for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery and ascertained their CR utilization. Neighborhood socioeconomic context was assessed using a neighborhood deprivation index derived from 11 census-tract level variables. We analyzed the association of CR utilization with neighborhood deprivation after adjusting for individual socioeconomic status. A total of 4096 SCCS participants (55% female, 57% black) with claims data were eligible for CR. CR utilization was low, with 340 subjects (8%) participating in CR programs. Study participants residing in the most deprived communities (highest quintile of neighborhood deprivation) were less than half as likely to initiate CR (odds ratio 0.42, 95% confidence interval, 0.27-0.66, P<0.001) as those in the lowest quintile. CR participation was inversely associated with all-cause mortality (hazard ratio 0.77, 95% confidence interval, 0.60-0.996, P<0.05). CONCLUSIONS:Lower neighborhood socioeconomic context was associated with decreased CR participation independent of individual socioeconomic status. These data invite research on interventions to increase CR access in deprived communities.

SUBMITTER: Bachmann JM

PROVIDER: S-EPMC5721841 | biostudies-other | 2017 Oct

REPOSITORIES: biostudies-other

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Association of Neighborhood Socioeconomic Context With Participation in Cardiac Rehabilitation.

Bachmann Justin M JM Huang Shi S Gupta Deepak K DK Lipworth Loren L Mumma Michael T MT Blot William J WJ Akwo Elvis A EA Kripalani Sunil S Whooley Mary A MA Wang Thomas J TJ Freiberg Matthew S MS

Journal of the American Heart Association 20171011 10

<h4>Background</h4>Cardiac rehabilitation (CR) is underutilized in the United States, with fewer than 20% of eligible patients participating in CR programs. Individual socioeconomic status is associated with CR utilization, but data regarding neighborhood characteristics and CR are sparse. We investigated the association of neighborhood socioeconomic context with CR participation in the SCCS (Southern Community Cohort Study).<h4>Methods and results</h4>The SCCS is a prospective cohort study of 8 ...[more]

PMID: 29021267

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Project description:ObjectivesThis study sought to examine the efficacy of financial incentives to increase Medicaid patient participation in and completion of cardiac rehabilitation (CR).BackgroundParticipation 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.MethodsA 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.ResultsPatients 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).ConclusionsFinancial 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).

Project description:ImportanceCardiac rehabilitation (CR) improves survival after acute myocardial infarction (AMI), and referral to CR has been introduced as a performance measure of high-quality care. The association of participation in CR with patients' health status (eg, quality of life, symptoms, and functional status) is poorly defined.ObjectiveTo examine the association of participation in CR with health status outcomes after AMI.Design, setting, and participantsA retrospective cohort study was conducted of patients enrolled in 2 AMI registries: PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008. The analytic cohort was restricted to 4929 patients with data available on baseline health status, 6- or 12- month follow-up health status, and participation in CR. Data analysis was performed from 2014 to 2015.ExposuresParticipation in at least 1 CR session within 6 months of hospital discharge.Main outcomes and measuresPatient health status was quantified using the Seattle Angina Questionnaire (SAQ) and the 12-Item Short-Form Health Survey (SF-12). The primary outcomes of interest were the mean differences in SAQ domain scores during the 12 months after AMI between patients who did and did not participate in CR. Secondary outcomes were the mean differences in the SF-12 summary scores and all-cause mortality.ResultsAfter successfully matching the cohorts of the 4929 patients (3328 men and 1601 women; mean [SD] age, 60.0 [12.2] years) for the propensity to participate in CR and comparing the groups using linear, mixed-effects models, mean differences in the SAQ and SF-12 domain scores were similar at 6 and 12 months between the 2012 patients participating in CR (3 were unable to be matched) and the 2894 who did not participate (20 were unable to be matched). At 6 months, the mean difference was -0.76 (95% CI, -2.05 to 0.52) for the SAQ quality of life score, -1.53 (95% CI, -2.57 to -0.49) for the SAQ angina frequency score, 0.38 (95% CI, -0.51 to 1.27) for the SAQ treatment satisfaction score, -0.42 (95% CI, -1.65 to 0.79) for the SAQ physical limitation score, 0.50 (95% CI, -0.22 to 1.22) for the SF-12 physical component score, and 0.13 (95% CI, -0.53 to 0.79) for the SF-12 mental component score. At 12 months, the mean difference was -0.89 (95% CI, -2.20 to 0.43) for the SAQ quality of life score, -1.05 (95% CI, -2.12 to 0.02) for the SAQ angina frequency score, 0.38 (95% CI, -0.54 to 1.29) for the SAQ treatment satisfaction score, -0.14 (95% CI, -1.41 to 1.14) for the SAQ physical limitation score, 0.17 (95% CI, -0.57 to 0.92) for the SF-12 physical component score, and 0.12 (95% CI, -0.56 to 0.80) for the SF-12 mental component score. In contrast, the hazard rate of all-cause mortality (up to 7 years) associated with participating in CR was 0.59 (95% CI, 0.46-0.75).Conclusions and relevanceIn a cohort of 4929 patients with AMI, we found that those who did and did not participate in CR had similar reported health status during the year following AMI; however, participation in CR did confer a significant survival benefit. These findings underscore the need for increased use of validated patient-reported outcome measures to further examine if and how health status can be maximized for patients who participate in CR.

Project description:Background: To help clarify a potential barrier to cardiac rehabilitation (CR) participation we sought to examine the association between musculoskeletal limitations (MSLs) and CR enrollment and participation. Methods: Consecutive CR eligible individuals hospitalized for a cardiac event (myocardial infarction, percutaneous coronary intervention, and/or coronary artery bypass graft) between the months of November 2007 and May 2008, were asked to complete a mailed survey within 2 weeks after hospital discharge, assessing demographic factors, Patient Health Questionnaire (PHQ-9), participation in CR and MSLs through a validated MSLs screening tool. CR enrollment rates were compared between patients with and without MSLs. Results: Three hundred and twenty-one (37%) of patients contacted responded to our survey, including 228 males (71%), with a mean age 68 ± 10.8 years, of whom 98% were Caucasian. Eighty-two percent of responders reported a musculoskeletal disorder at the time of hospital discharge. Arthritis was the most frequent diagnosis (45%). Muscle or joint pain sufficient to limit the ability to do moderate exercise was reported in 52% of the respondents. Problems with balance affected 37%, of whom 45% reported a fall within the previous year. No significant difference in CR enrollment was observed in respondents with and without MSLs [OR = 0.98, 95% CI (0.88-1.09), p = 0.750]. Similar results were found when severity and number of MSLs were taken into account. However, we found that when compared to those without MSLs, the presence of MSLs was associated with lower CR participation (OR = 0.80, 95%, CI: 0.65-0.97, p = 0.0252). Conclusion: Despite a high prevalence of MSLs among CR-eligible patients, we found no association between MSLs and CR enrollment. However, patients with MSLs attended significantly fewer CR sessions as compared to patients without them. CR programs should consider providing additional support and interventions to patients with MSLs in order to optimize their adherence to prescribed CR sessions.

Project description:BackgroundThe impact of the COVID-19 pandemic on participation in and availability of cardiac rehabilitation (CR) is unknown.MethodsAmong eligible Medicare fee-for-service beneficiaries, we evaluated, by month, the number of CR sessions attended per 100 000 beneficiaries, individuals eligible to initiate CR, and centers offering in-person CR between January 2019 and December 2021. We compared these outcomes between 2 periods: December 1, 2019 through February 28, 2020 (period 1, before declaration of the pandemic-related national emergency) and October 1, 2021 through December 31, 2021 (period 2, the latest period for which data are currently available).ResultsIn period 1, Medicare beneficiaries participated in (mean±SD) 895±84 CR sessions per 100 000 beneficiaries each month. After the national emergency was declared, CR participation sharply declined to 56 CR sessions per 100 000 beneficiaries in April 2020. CR participation recovered gradually through December 2021 but remained lower than prepandemic levels (period 2: 698±29 CR sessions per month per 100 000 beneficiaries, P=0.02). Declines in CR participation were most marked among dual Medicare and Medicaid enrollees and patients residing in rural areas or socially vulnerable communities. There was no statistically significant change in CR eligibility between the 2 periods. Compared with 2618±5 CR centers in period 1, there were 2464±7 in period 2 (P<0.01). Compared with CR centers that survived the pandemic, 220 CR centers that closed were more likely to be affiliated with public hospitals, located in rural areas, and serve the most socially vulnerable communities.ConclusionsThe COVID-19 pandemic was associated with a persistent decline in CR participation and the closure of CR centers, which disproportionately affected rural and low-income patients and the most socially vulnerable communities. Innovation in CR financing and delivery is urgently needed to equitably enhance CR participation among Medicare beneficiaries.

Dataset Information

Association of Neighborhood Socioeconomic Context With Participation in Cardiac Rehabilitation.

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Association of Neighborhood Socioeconomic Context With Participation in Cardiac Rehabilitation.

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