Author + information
- Published online June 24, 2019.
- Gordon R. Reeves, MD, MPT∗ ( and )
- David J. Whellan, MD, MHS
- Department of Medicine, Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania
- ↵∗Address for correspondence:
Dr. Gordon R. Reeves, Department of Medicine, Division of Cardiology, Thomas Jefferson University, 925 Chestnut Street, Mezzanine, Philadelphia, Pennsylvania 19107.
Cardiac rehabilitation (CR) is among the most underutilized evidence-based, guideline-directed therapy in cardiovascular medicine. Underutilization involves all phases of delivery of this therapy, including identification of appropriate patients, under-referral of eligible populations, low enrollment among those referred, and poor adherence among those who enroll. Consequently, less than one-third of eligible patients participate and <20% of those patients complete all 36 sessions typically covered by third-party payers (1,2). While advances such as automated referral systems have made gains in referral rates, additional strategies targeting enrollment and adherence are needed. Such strategies may be of particular importance because the benefits of CR appear to be dependent on the number of sessions attended (2).
In this issue of JACC: Heart Failure, Gaalema et al. (3) take an important step forward in addressing this issue through the use of financial incentives aimed at improving adherence to CR. In a pilot study, the investigators targeted lower-socioeconomic status (SES) patients participating in Medicaid and randomized 130 individuals who had a CR-qualifying event to receive financial incentives and the remaining patients to usual care. The participants, all of whom agreed to participate in CR prior to randomization, were primarily enrolled following hospitalization for a coronary artery disease-related event (≥75%); <10% were referred primarily for heart failure, highlighting the particularly striking low use of CR for heart failure, which is consistent with previous reports (4). Most patients were white (94%), 42% were smokers, and obesity was common (average body mass index [BMI]: 32 kg/m2). The financial incentives were as low as $4 for participating in an exercise session and increased by $2 per session to a maximum of $50 for each session attended. Missed sessions resulted in a return to $4 but the incentive could be “reset” to the prior level once adherence was re-established. Under this scheme, participants earned an average of $716 in incentives (of maximum potential of $1,238) or, by our calculation, approximately $32 per session.
What was the return on this investment? Participants with incentives completed approximately 50% more sessions (22.4 vs. 14.7, respectively; p = 0.013), and nearly twice as many participants completed CR, defined as attendance at least 30 of a possible 36 sessions (55.4% vs. 29.2%, respectively; p = 0.002), both of which were significantly better with incentives. The average number of hospital contacts per participant in the year following enrollment was less common among those who completed CR (1.30 vs. 2.55, respectively; p = 0.012) with trends favoring those in the incentive arm (1.62 vs. 2.48; p = 0.079). Limited cost analysis showed the incremental cost-effectiveness ratio for projected added life-years was $9,336.
We would like to commend Gallema et al. (3) for taking on the formidable challenge of improving CR adherence and for evaluating the use of financial incentives to achieve this goal, an intervention that is likely not without some controversy. Potential concerns surrounding the use of financial incentives to influence health behavior include: 1) paying patients for doing “what they should be doing anyway,” potentially undermining personal responsibility and sustained positive behavior change; 2) the potential to be coercive and undermining autonomy; 3) targeting those of low socioeconomic status, with the potential to be stigmatizing; and 4) the risk of recruiting a skewed sample more likely to be motivated by financial incentives than the broader population such that the study over-estimates the “real-world” impact of the incentives (5). Careful thought regarding structure and implementation of financial incentives as well as monitoring of performance and unforeseen consequences are needed to mitigate these concerns and justify the use of financial incentives despite them.
Nonetheless, financial incentives have been used to improve adherence and chronic disease management in other populations, and CR adherence may be a particularly attractive target for financial incentives for multiple reasons. First, costs may represent a significant barrier to CR participation. Costs related to co-pays, which are common for CR, even when covered by insurance, can adversely impact adherence in other populations (6). Even if co-pays were eliminated, as was the case in both arms of the current study, potential CR participants face actual and opportunistic costs associated with time and travel to and from CR, typically 3 days per week, including parking, transportation, need for child or elder care, missed time from work, and so forth. The cumulative cost over 3 months may constitute a significant barrier to participate, even among those who desire to do so. Patients from low SES may be at greater risk from this financial deterrent.
Second, CR is delivered in a time frame where financial incentives are most likely to be effective. The findings from the present study are consistent with previous research showing financial incentives improve adherence to exercise, at least in the short term (<6 months) (7). Finally, even short-term improvement in CR adherence could have sustained benefit, as CR participation has been associated with a dose-related improvement in long-term clinical outcomes (2). Such benefit, if confirmed through prospective studies, would help justify the use of financial incentives for clinical benefit, and reduced clinical event rates could help offset costs, potentially making financial incentives cost neutral or even cost saving among the high-risk groups commonly targeted for CR.
Based on these factors and the encouraging findings in the study by Gaalema et al. (3), we look forward to additional studies to address a number of important, unanswered questions regarding the use of financial incentives in CR populations. What is the optimal structure and amount of incentives? Will improved adherence to comprehensive CR lead to improved adherence to other health-related behaviors important to the management of chronic disease (e.g., adherence to medication regimens, dietary recommendations, clinic attendance, and others)? Will similar success be achieved across more diverse patient populations and practice settings? Will improved CR participation through financial incentives lead to better quality of life and improved short-term and long-term clinical outcomes? What will be the net financial impact of such incentives to the health care system?
However, even if further research leads to more widespread use of financial incentives, the study findings by Gaalema et al. (3) also show that financial incentives alone will not be enough to fully address the issue of poor adherence to CR. Nearly one-half the participants failed to complete CR despite the use of financial incentives in a motivated population. Additional strategies clearly will be needed to meet the needs of the substantial number of patients who will not respond to financial incentives alone. This could include, for example, alternative CR designs, such as delivery in the home as well as tailoring CR to meet individual rehabilitation needs, particularly in the elderly whose physical impairments may impede participation in conventional CR (8)
The ability for financial incentives to change patient behavior is already having an impact on health care policy. Shifting health care costs to individuals is 1 step in that direction. The next step is linking better adherence to proven interventions, including cardiac rehabilitation, to financial benefit for the individual. Insurers, including the employer-based product used by the authors, are helping to make this connection by offering reduced deductibles for healthy behaviors, including exercise. The more widespread use of such programs may help diminish any stigma associated with financial incentives like this one and could prove to be a worthwhile investment if linked to reduced clinical events and improved quality of life.
↵∗ Editorials published in JACC: Heart Failure reflect the views of the authors and do not necessarily represent the views of JACC: Heart Failure or the American College of Cardiology.
Drs. Reeves and Whellan have received research funding through a U.S. National Institutes of Health grant R01AG045551.
- 2019 American College of Cardiology Foundation
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