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Lower-Socioeconomic Status Patients Have Extremely High-Risk Factor Profiles on Entry to Cardiac Rehabilitation
Sherrie Khadanga1, Patrick D Savage, Philip A Ades
1University of Vermont Medical Center, Burlington (Drs Khadanga and Ades and Messrs Savage and Anair); and University of Vermont, Burlington (Mr Yant, Ms Kromer, and Dr Gaalema).
Insights
Patients with lower socioeconomic status (SES) face higher cardiovascular risks and are less likely to join cardiac rehabilitation (CR). This study highlights their distinct high-risk profile, emphasizing the need for targeted CR engagement strategies.
Area of Science:
- Cardiology
- Public Health
- Health Disparities
Background:
- Patients with lower socioeconomic status (SES) experience disproportionately higher rates of cardiovascular events.
- Lower SES is associated with reduced engagement in secondary prevention programs like cardiac rehabilitation (CR).
- Characterizing the unique risk factors of lower-SES patients in CR has been challenging due to low enrollment.
Purpose of the Study:
- To compare medical, psychosocial, and behavioral risk factors between lower- and higher-SES patients eligible for secondary prevention.
- To characterize the high-risk profile of lower-SES patients within a CR program that successfully increased their recruitment.
- To identify specific areas for intervention within CR for lower-SES individuals.
Main Methods:
- Prospective data collection on consecutive patients entering phase 2 CR from 2014 to 2022.
- Classification of lower SES based on Medicaid insurance status.
- Statistical analysis using chi-square and nonpaired t tests with significance set at P < .01.
Main Results:
- Lower-SES patients (13% of 3131 cohort) were younger (57 vs 67 years) but had higher rates of current smoking (29% vs 5%), elevated depressive symptoms (1.7x), and worse cardiometabolic markers (BMI, waist circumference, HbA1c, lipids).
- Despite being younger, lower-SES patients exhibited lower cardiorespiratory fitness and self-reported physical function.
- These findings were statistically significant (all P < .001).
Conclusions:
- Lower-SES patients present with a significantly higher-risk cardiovascular disease profile, indicating a greater likelihood of recurrent coronary events.
- Enhanced engagement strategies are crucial to enroll this high-risk population into CR.
- CR programs must be equipped to address modifiable risk factors prevalent in lower-SES patients, including low fitness, obesity, depression, and smoking.
Purpose:
Patients with lower socioeconomic status (SES) have higher rates of cardiovascular events, yet are less likely to engage in secondary prevention such as cardiac rehabilitation (CR). Given the low number of lower-SES patients entering CR, characterization of this population has been difficult. Our CR program specifically increased recruitment of lower-SES patients, allowing for careful comparison of medical, psychosocial, and behavioral risk factors between lower- and higher-SES patients eligible for secondary prevention.
Methods:
Demographic and clinical characteristics were prospectively gathered on consecutive individuals entering phase 2 CR from January 2014 to December 2022. Patients were classified as lower SES if they had Medicaid insurance. Statistical methods included chi-square and nonpaired t tests. A P value of <.01 was used to determine significance.
Results:
The entire cohort consisted of 3131 individuals. Compared with higher-SES patients, lower-SES individuals (n = 405; 13%) were a decade younger (57.1 ± 10.4 vs 67.2 ± 11.2 yr), 5.8 times more likely to be current smokers (29 vs 5%), 1.7 times more likely to have elevated depressive symptoms, and significantly higher body mass index, waist circumference, and glycated hemoglobin A 1c , with more abnormal lipid profiles (all P s < .001). Despite being a decade younger, lower-SES patients had lower measures of cardiorespiratory fitness and self-reported physical function (both P s < .001).
Conclusion:
Lower-SES patients have a remarkably prominent high-risk cardiovascular disease profile, resulting in a substantially higher risk for a recurrent coronary event than higher-SES patients. Accordingly, efforts must be made to engage this high-risk population in CR. It is incumbent on CR programs to ensure that they are appropriately equipped to intervene on modifiable risk factors such as low cardiorespiratory fitness, obesity, depression, and smoking.
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