RS23 - Incentives and Individualized Coaching Improves Completion Rates of Supervised Exercise Therapy for Claudication

Objectives: Supervised exercise therapy (SET) provides clinical benefit for patients suffering from intermittent claudication and has been widely remarked as first-line therapy before surgical intervention. However, published rates of SET program completion range from 5 to 55%, with historic completion of 54% at our own institution. As such, we sought to identify if targeted patient-supportive interventions improve SET completion rates while still maintaining efficacious SET programming.

Methods: Patients who were diagnosed with intermittent claudication, as defined by ankle-brachial index (ABI) < 0.9 without rest pain, were offered enrollment in a prospective quality improvement protocol for our 12-week SET program. Program completion was defined as ≥24/36 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 our advanced practitioner staff, and informational materials on the importance of SET programming and lifestyle modification. Patient-reported improvements in walking symptoms were tracked via regularly administered questionnaires. Functional measures of SET programming including total walking duration and distance, metabolic equivalent of task (METs), ABIs, and vascular intervention 12-months after completion were also collected and compared using univariate paired analysis.

Results: In total, 56 patients completed SET programming, while 120 patients did not complete SET or declined participation. Utilizing our three-pronged coaching approach, we increased our SET completion rate to 74.7% over a 2-year study period. Compared to pre-SET baseline, patients who completed SET noted less pain, aching, cramps in calves when walking (p=0.004) and less difficulty walking 1 block (p=0.038). Additionally, patients significantly increased their METs (3.1 vs 2.6, p< 0.001), total walking duration (30mins vs 13.5mins, p< 0.001), and total walking distance (0.7mi vs 0.3mi, p< 0.001) from their pre-SET baseline. There were no changes in participant ABIs from enrollment to completion in participants (0.7 vs 0.7, p=0.641). Patients who completed SET programming also delayed vascular intervention compared to those who did not complete SET or declined participation (188 vs 118 days from enrollment, p=0.009).

Conclusions: Targeted incentives including cost-coverage vouchers and personalized coaching with instructional materials successfully improved patient completion of a prescribed SET program. Patients who completed SET programming with incentives demonstrated improvement in reported walking symptoms and objective walking benefits. In addition, these patients had delayed time to vascular intervention, supporting current vascular guidelines advocating for effective SET therapy prior to offering vascular intervention for intermittent claudication.