BMC Cardiac Rehab Program Achieves Equal Outcomes Across Income Levels 

Exercise-based cardiac rehabilitation is proven to be an essential part of care management for cardiovascular disease, reducing symptoms, preventing future hospitalizations, and improving overall prognosis. However, access and adherence to these rehab programs remain persistently low on the global, national, and local scale—particularly among low-income populations. When cardiovascular disease is the leading cause of mortality in the U.S., with people from low-income communities dying at much higher rates, effective programming is vital. In a new study, Boston Medical Center (BMC) sought to investigate its own Cardiac Rehabilition Program to assess how socioeconomic status impacts patient outcomes and adherence rates, working to uncover obstacles and improve care. 

The recently published study in the Journal of Cardiopulmonary Rehabilitation and Prevention, researchers looked at data the team has been collecting from its program since 1992—BMC’s cardiac rehab program is one of New England’s oldest. Researchers found that attendance, adherence rates, and patient outcomes did not vary across patients with varying socioeconomic status—meaning that patient outcomes from the program were consistent across your income and ability to pay.  

Researchers attribute this to the program’s holistic approach to patient care and its vigilance in evolving to meet its patients’ needs within the program and outside of it. 

A deeper dive into BMC’s cardiac rehab program study 

BMC researchers analyzed data from a pool of 770 consecutive enrollees in its Cardiac Rehabilitation program between 2016 and 2019. They used a U.S. Census tool called Area Deprivation Index (ADI), which rates an individual’s socioeconomic hardship based on factors such as income, education, employment, and housing within a given zip code. 

They looked into program adherence data, which is defined as a 70% attendance rate, and the actual percentage of attendance based on patient ADI. They also tracked health and behavior improvements in fitness, mood, diet, and weight loss after rehabilitation. 

“Here at Boston Medical Center, where we try our best to accommodate the needs of our patients, it looks like there’s no difference among the groups in terms of their outcomes.”

Gary Balady, MD, director of Non-invasive Cardiovascular Labs and Preventive Cardiology at BMC

The analysis revealed that adherence among BMC cardiac rehabilitation patients was the same across different socioeconomic statuses. ADI ranking did not influence attendance or adherence to the program, a finding that remained consistent when further analyzed by race and ethnicity. Strikingly, however, all secondary outcomes except for weight loss (e.g., diet and cholesterol) showed statistically significant improvements. 

“Here at Boston Medical Center, where we try our best to accommodate the needs of our patients, it looks like there’s no difference among the groups in terms of their outcomes,” says Gary Balady, MD, director of Non-invasive Cardiovascular Labs and Preventive Cardiology at BMC. 

The cardiac rehab program and wraparound care 

Established in 1985, the Cardiac Rehabilitation Program is housed within BMC’s Cardiovascular Center. The multidisciplinary rehab team provides exercise training, nutritional counseling, and cardiovascular risk factor modification for patients who have heart disease, including coronary artery disease; recent heart valve surgery; and heart failure. 

From beginning to end, patients complete three sessions per week for eighteen weeks. This can be a demanding schedule, and there are many obstacles to address to be able to complete it, including transportation, childcare, job hours, and much more. To support patients through attendance and adherence to the program, the Cardiac Rehabilitation Program teams try to tailor it to an individual patient’s needs and lifestyle. They address language barriers, adjust hours so people can fit appointments in their schedules, use BMC’s Teaching Kitchen and Preventative Food Pantry to assist with food security and nutrition, and help with transportation to and from cardiac rehab. 

“Sometimes people need to take two buses and a train to get to appointments. So, we’ll arrange for Uber Health rides if they are not able to manage public transport and have no other means of transportation. If they decide to drive, we’ll pay for their parking,” Balady says. “We try and remove that transportation barrier—which is a big barrier.” 

A key element of BMC’s program is not just that the wraparound supports are in place, it’s that they aren’t static. The teams are constantly looking at their own data and listening to feedback from patients about barriers and obstacles to care. With that information, they are initiating new services and options that will ideally break down or mitigate those barriers. 

“Our study highlights the importance of continually identifying barriers that exist within our healthcare system that place increased undue burden on patients that have been referred for CR and remaining vigilant and relentless in our attempt to mitigate these barriers to improve compliance and decrease drop-out,” reads the journal article. 

Looking to the future in cardiac rehabilitation adherence 

While showcasing many successes, the recent study also underlined a persistent issue in cardiac rehab programs generally: adherence. Cardiac Rehabilitation programs report a drop-out rate of 24-50% across the U.S. The high drop-out rate is a factor in increased risk of recurrent cardiac events. 

“When you’re asking somebody to come three times a week, work out, and do that for 18 weeks, it is not an easy thing to do. Adherence is a big issue in the whole field of cardiac rehab,” explains Balady. 

Researchers are investigating if health-prompting interventions can help improve adherence. At BMC, patients are offered a mobile technology support app, available in both English and Spanish, that enables direct communication with the care team, tracks physical activity, and provides health education. 

“We tailor our care so it’s realistic to the busy lives our patients have outside of the program. The app allows patients to do parts of their program like guided exercises, check-ins with their provider, or telemedicine with their nutritionist on their own time.” says Stephanie Zombeck, exercise physiologist and program manager at BMC’s Cardiac Rehabilitation Center. 

Currently, about 20% of BMC Cardiac Rehabilitation patients use the application, which has been shown to improve adherence. It’s one example of how BMC teams report being relentless in their desire to look at the data and evolve their program to meet needs. 

“We have a lot of experience in cardiac rehab. We’re proud of our history, but we’re always looking to improve. That’s why we have our outcomes database,” Balady says. “One of the key points of our program is we’re not doing what we did back in 1985 when we started. We’re bigger and better and always looking to the future.”