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Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT02172820
Recruitment Status : Completed
First Posted : June 24, 2014
Results First Posted : June 11, 2019
Last Update Posted : June 11, 2019
National Institute of General Medical Sciences (NIGMS)
Information provided by (Responsible Party):
Diann Gaalema, University of Vermont

Brief 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. Medicaid coverage and similar state-supported insurance are robust predictors of CR non-participation. There is growing recognition of the need to increase CR among patients with this form of insurance and other economically disadvantaged patients, but there are no evidence-based interventions available for doing so. In the present study we are examining the efficacy of using financial incentives for increasing CR participation among Medicaid patients. Financial incentives have been highly effective in altering other health behaviors among disadvantaged populations (e.g., smoking during pregnancy, weight loss). For this study are randomizing 130 CR-eligible Medicaid enrollees to a treatment condition where they receive financial incentives contingent on initiation of and continued attendance at CR sessions or to a "usual-care" condition where they will not receive these incentives. Treatment conditions will be compared on attendance at CR and end-of-intervention improvements in fitness, decision making and health-related quality of life. Cost effectiveness of the treatment conditions will also be examined by comparing the costs of the incentive intervention and usual care conditions with their effects on increasing CR initiation and adherence. Should this intervention be efficacious and cost-effective, it has the potential to substantially increase CR participation and significantly improve health outcomes among low-income cardiac patients.

Condition or disease Intervention/treatment Phase
Coronary Artery Disease Behavioral: Financial incentives Not Applicable

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 130 participants
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Increasing Cardiac Rehabilitation Participation Among Medicaid Enrollees
Actual Study Start Date : April 2014
Actual Primary Completion Date : July 2017
Actual Study Completion Date : February 2018

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
Experimental: Financial incentives
Participants receive financial incentives for completing exercise sessions.
Behavioral: Financial incentives
Patients in the experimental group will receive financial incentives for completing exercise sessions.

No Intervention: Control
Participants receive an equal amount of clinical contact but no financial incentives for completing exercise visits.

Primary Outcome Measures :
  1. Attendance at Cardiac Rehabilitation Exercise Sessions [ Time Frame: Within 4 months of initial stress test ]
    The number of patients who completed cardiac rehabilitation (CR) as defined as greater than or equal to 30 sessions. Must have been completed within 4 months of the entry stress test.

Secondary Outcome Measures :
  1. Change in Physical Health [ Time Frame: Intake, 4 months ]
    Secondary outcomes included changes between baseline and 4-month assessment in fitness (peak oxygen uptake directly measured by expired gas analysis or estimated by metabolic equivalents), body composition (body mass index, waist circumference), and quality of life (MacNew).The MacNew was designed to evaluate how daily activities and physical,emotional and social functioning are affected by heart disease and its treatment. It consists of 27 questions grouped into 3 domains: physical, mental and social functioning. Both subscales and summary score are interpreted as scores between 1 and 7; higher scores are better, and a change of at least 0.5 is a useful indicator of the minimal important difference.Changes over time were assessed using paired differences in scores from intake to four months. Due to non-normal distributions, Wilcoxon Signed Rank Test was used. Contributions of other variables to changes in secondary outcomes were examined using analyses of covariance.

  2. Changes in Mental Health/Cognition [ Time Frame: Changes in socio-cognitive measures will be measures from intake to completion of intervention (4 months) ]
    The Achenbach System of Empirically Based Assessment (ASEABA) is an integrated system of multi-informant assessments, including self-reports, to measure adaptive functioning and problems. The problem items have been factor-analytically reduced to 8 syndrome scales that are consistent across age, informant and culture. Higher scores represent higher symptoms (e.g. emotional/behavioral problems). The Stop Signal Reaction Time (SSRT) task measures the ability to inhibit incorrect responses. Lower scores represent a better ability to inhibit reactions. The BRIEF-A is a rating scale developed to look at everyday behaviors associated with specific domains of executive functions in adults ages 18-90.T-scores (standardized scores) are used to interpret the individual's level of executive functioning (EF). Higher scores represent more self-reported problems. A score of 50 represents the mean.A difference of 10 from the mean indicates a difference of one standard deviation (SD).

Other Outcome Measures:
  1. Maintenance of Physical Health Gains Following Intervention. [ Time Frame: 4 months and 1 year. ]
    Changes in measures of physical health and fitness (peak oxygen uptake, metabolic equivalents, waist circumference, BMI, treadmill time, smoking status, perceived quality of life) will be measured from completion of intervention (4 months) to 8 months later (1 year follow-up).

  2. Maintenance of Mental Health/Cognition Scores Following Intervention. [ Time Frame: 4 months and 1 year. ]
    Changes in measures of mental health (Beck Depression Inventory, Adult Self-Report) as well as changes in measures of executive function (Trail Making and Tower tasks, Delay Discounting, Time Perspective Questionnaire, Stop Signal Task, Behavior Rating Inventory of Executive Function) will be measured from completion of intervention (4 months) to 8 months later (1 year follow-up).

  3. Health Care Costs [ Time Frame: From intake to one year follow-up ]
    Health care costs (cost of delivering care at the cardiac rehabilitation clinic as well as hospital costs) will be calculated from study entry to one year follow-up.

  4. Costs of Attending Care [ Time Frame: Intake to 1 year follow-up ]
    Costs to the patient of attending care (transportation, child/elder care, missed wages) will be calculated from study entry to one year follow-up.

Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • A recent myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, heart valve replacement or repair, or stable heart failure.
  • Enrolled in a state-supported insurance plan for low income individuals
  • Lives in and plans to remain in the greater Burlington, Vermont area (Chittenden County) for the next 12 mos.

Exclusion criteria:

  • Dementia (MMSE<20) or current untreated Axis 1 psychiatric disorder other than nicotine dependence as determined by medical history
  • Non-English speaking
  • Prior participation in cardiac rehabilitation
  • Advanced cancer, advanced frailty, or other longevity-limiting systemic disease that would preclude CR participation
  • Rest angina or very low threshold angina (<2 METS) until adequate therapy is instituted
  • Severe life threatening ventricular arrhythmias unless adequately controlled (e.g. intracardiac defibrillator)
  • Class 4 chronic heart failure (symptoms at rest)
  • Exercise-limiting non-cardiac disease such as severe arthritis, past stroke, severe lung disease

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT02172820

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United States, Vermont
University of Vermont
Burlington, Vermont, United States, 05401
Sponsors and Collaborators
University of Vermont
National Institute of General Medical Sciences (NIGMS)
  Study Documents (Full-Text)

Documents provided by Diann Gaalema, University of Vermont:
Study Protocol  [PDF] June 27, 2011
Informed Consent Form  [PDF] March 24, 2015
Statistical Analysis Plan  [PDF] June 27, 2011

Publications automatically indexed to this study by Identifier (NCT Number):
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Responsible Party: Diann Gaalema, Assistant Professor of Psychiatry, University of Vermont Identifier: NCT02172820    
Other Study ID Numbers: CRINCN9874
P20GM103644 ( U.S. NIH Grant/Contract )
First Posted: June 24, 2014    Key Record Dates
Results First Posted: June 11, 2019
Last Update Posted: June 11, 2019
Last Verified: May 2019
Keywords provided by Diann Gaalema, University of Vermont:
cardiac rehabilitation
contingency management
Additional relevant MeSH terms:
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Coronary Artery Disease
Coronary Disease
Myocardial Ischemia
Heart Diseases
Cardiovascular Diseases
Arterial Occlusive Diseases
Vascular Diseases