Incentives and Case Management to Improve Cardiac Care: Healthy Lifestyle Program

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. The
present study will examine 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 a
prior trial. For this study 200 CR-eligible lower-SES patients will be randomized to: a
treatment condition where patients are assigned a case manager while in hospital who will
facilitate CR attendance and coordinate cardiac care, a treatment condition where patients
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, the value of the interventions will be modeled 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
testing of 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.