Incentives and coaching offer promise for improving supervised exercise therapy completion in claudicants

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Colin Cleary

Study findings were presented during Saturday, June 22’s Plenary Session 7 support current vascular guidelines advocating for effective supervised exercise therapy (SET) prior to offering vascular intervention for patients with intermittent claudication. That is the belief of Colin Cleary, PhD, a fourth-year medical student at the University of Connecticut School of Medicine in Farmington, and his co-authors.

“Current guidelines by the SVS [Society for Vascular Surgery] support the use of effective supervised exercise therapy programming as first-line therapy for all patients with intermittent claudication. These guidelines are supported by primary literature that supports the use of SET before any vascular intervention for symptomatic, flow-limiting arterial disease,” Cleary tells VS@VAM. “However, during this study, we found that patients were motivated much more to complete programming primarily from individualized coaching, and that patients who completed programming were more likely to delay their vascular interventions.”

Published rates of SET program completion range from 5% to 55%. Cleary and colleagues note, for example, a historical completion rate of 54% at their own institution. As such, they sought to identify if targeted patient-supportive interventions—including financial incentives and individualized coaching—can improve completion rates while still maintaining efficacious SET programming. Cleary et al undertook a research effort whereby patients who were diagnosed with intermittent claudication were offered enrollment in a prospective quality improvement protocol for a 12-week SET program at outpatient sites through Hartford HealthCare. Program completion was defined as ≥24 of the 36 offered sessions over 12 weeks.

A three-pronged approach was utilized to improve completion during the study, including financial incentives up to $180, scheduled coaching with advanced practitioner staff, and informational materials on the importance of SET programming and lifestyle modification. Patient-reported improvements in walking symptoms were tracked and analyzed, as were several functional measures of SET programming—including total walking duration and distance, metabolic equivalent of task (METs), ankle-brachial indices (ABIs), and vascular intervention 12 months after completion. In total, 56 patients completed SET programming, while 120 either did not complete SET or declined participation.

Utilizing this approach, Cleary et al increased their SET completion rate to 74.7% over a two-year study period. Compared to pre-SET baseline, patients who completed SET noted less pain, aching, cramps in calves when walking and less difficulty walking one block. Additionally, patients significantly increased their METs, total walking duration and total walking distance from their preSET baseline. And, while the researchers report participant ABIs remaining unchanged from enrollment to completion, they did find that patients who completed SET programming had delayed vascular intervention compared to those who either did not complete SET or declined participation. Cleary highlights a potentially key factor: patients with public insurance had a median out-of-pocket expense of $0 per visit compared to $6 for those with private insurance, which the researchers note could add up to a total of more than $200 across the full program.

They conclude that targeted incentives including cost-coverage vouchers and personalized coaching were able to improve patient completion of a prescribed SET program. Cleary et al add that patients who completed SET programming with incentives demonstrated improvement in reported walking symptoms and objective walking benefits—and that the patients studied had a delayed time to vascular intervention.

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