Improving Participation in Cardiac Rehabilitation among Lower-Socioeconomic Status Patients: Efficacy of Early Case Management and Financial Incentives

项目摘要 参与门诊心脏康复（CR）可降低住院患者的发病率和死亡率 心肌梗死、冠状动脉搭桥手术或经皮血运重建。不幸的是，只有10- 有CR指征的患者中有35%选择参与研究。较低的社会经济地位（SES）是一个强大的 CR不参与的预测因素。越来越多的人认识到有必要在经济上提高CR 弱势患者，但几乎没有循证干预措施可用于这样做。在 目前的研究，我们正在研究使用早期病例管理和经济激励的有效性， 增加低SES患者的CR参与率。个案管理在促进 参加各种与健康相关的项目（如糖尿病、艾滋病、哮喘、可卡因治疗 （二）减少住院治疗。财政激励措施在改变 弱势群体的健康行为（例如，怀孕期间吸烟，减肥），包括 CR参与我们之前的试验。在本研究中，我们将200例符合CR条件的低SES患者随机分配至：a 在住院期间指定病例经理以促进CR的治疗条件 参与并协调心脏护理，这是一种治疗条件，他们可以获得经济奖励 取决于开始和继续出席公约与建议委员会会议，这两种干预措施相结合， 或“日常护理”状况。所有条件下的受试者将完成治疗前和治疗后评估。 治疗条件将在CR时的出勤率和干预结束时的健康改善方面进行比较， 执行功能和健康相关的生活质量。治疗条件的成本效益也将是 通过比较提供干预措施的成本和通常的护理条件， 增加了CR参与。此外，我们将根据以下因素对干预措施的价值进行建模： 参与率，干预费用，长期医疗费用和健康结果的增加 冠心病事件这种对有希望的干预措施的系统检查将使我们能够测试其功效， 有可能大幅度增加公约与建议委员会参与的方法的成本效益， 显著改善低SES心脏病患者的健康结果。

PROJECT SUMMARY 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.