Financial incentives boost participation in cardiac rehab

Heart patients of a lower socioeconomic status are far more likely to participate in cardiac rehabilitation if they receive financial incentives to attend sessions, according to a study published in the July 1 edition of JACC: Heart Failure.

Despite being the standard of care after a major cardiac event, participation in cardiac rehabilitation (CR) is poor across the U.S., Diann E. Gaalema, PhD, an assistant professor of psychiatry and psychology at the University of Vermont, and colleagues wrote in JACC. CR can lower heart patients’ risk of CV mortality 26%, reduce one-year hospital readmissions 31% and decrease patients’ odds of five-year all-cause mortality up to 34%, yet overall attendance rates for eligible patients are as low as 14%.

Participation is even worse in lower-socioeconomic status (SES) individuals—a subset of patients already prone to double the risk of one-year mortality than their more affluent peers. Research has found that within a population of Medicare patients aged 65 and up, those also enrolled in Medicaid attended CR at 20% to 45% the rate of higher-SES patients.

“Patients must also be retained in CR,” Gaalema et al. wrote, noting that at least a quarter of attendees fail to complete their programs. “Lower-SES patients complete fewer sessions than their higher-SES counterparts. Given that completing more CR sessions is associated with greater health benefits, the crucial outcome should not be to increase enrollment alone but to maximize the number of sessions completed.”

The authors’ study randomized 130 Medicaid beneficiaries with CR-qualifying cardiac events 1:1 to receive usual care or financial incentives for completing CR sessions. Patients randomized to the incentive arm received money on an escalating scale, ranging from $4 for a single session to $50 for completing the 36th and final outpatient exercise session.

Heart patients who received incentives to attend CR completed, on average, seven and a half more sessions than controls (22.4 vs. 14.7, respectively), Gaalen and co-authors reported. They were also nearly twice as likely to complete the CR program—55.4% vs. 29.2% of controls—and were more likely to see improvements in executive function.

The researchers said individuals who completed 30 or more CR sessions had 47% fewer combined hospitalizations and emergency department visits than controls, which was reflected by a nonsignificant trend by study condition with 39% fewer hospital contacts in the incentivized group.

Participants who were randomized to the incentive arm earned an average of $716 over the study period, or $32 per session. The base pay for attending a session was $4, and incentives increased $2 per consecutive session attended for a maximum potential sum of $1,238.

In a related editorial, Thomas Jefferson University’s Gordon R. Reeves, MD, MPT, and David J. Whellan, MD, MHS, commended Gaalema and her team for taking on an intervention that’s “likely not without some controversy.” 

“Potential concerns surrounding the use of financial incentives to influence health behavior include paying patients for doing ‘what they should be doing anyway,’ potentially undermining personal responsibility and sustained positive behavior change; the potential to be coercive and undermining autonomy; targeting those of low-SES with the potential to be stigmatizing; and the risk of recruiting a skewed sample more likely to be motivated by financial incentives than the broader population,” Reeves and Whellan wrote. 

“Careful thought regarding structure and implementation of financial incentives, as well as monitoring and performance of unforeseen consequences, are needed to mitigate these concerns and justify the use of financial incentives despite them.”