Lower Socioeconomic Status Associated with Decreased Completion of Exercise Rehabilitation in Patients with Pulmonary Hypertension

Abstract

Purpose Patients with pulmonary hypertension (PH) who concurrently have low socioeconomic status (SES) present with more advanced illness and have increased risk of death. Exercise rehabilitation is an underutilized therapy that improves exercise capacity and quality of life. Whether disparities in rehabilitation completion exist is unknown. Methods We performed a cross-sectional survey of patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH) who attended the PH Association (PHA) Research Room during the biennial conference. Participants completed a survey of demographic and clinical characteristics that inquired about prior referral and completion of rehabilitation and the MacArthur Scale of Subjective Social Status (MSSS). The MSSS is a validated survey of SES that asks participants to rate where they are on a ladder ranging from 1-10 in regards to income, occupation, or education compared to other people in the US. The primary outcome was completion of rehabilitation defined as attendance at >75% of sessions. The primary predictor was SES as measured by the MSSS grouped in tertiles. Multivariable logistic regressions performed to examine association between SES and rehabilitation completion adjusted for age and WHO functional class. Using the final model, the predicted probability of completion by SES tertile was estimated. Results We enrolled 62 participants with a mean age of 51.5 (± SD; 15.1) years, of whom 87% (n =52) were female. 48.4% (n = 30) had never been referred, 4.8% (n = 3) were referred and didn't complete, and 51.6% (n = 32) had completed rehabilitation. In the multivariable analysis, participants in the lowest SES tertile had greater than 80% lower odds of being referred and completing rehabilitation than participants in the highest SES tertile (OR 0.17, 95% CI 0.04 - 0.78; p value = 0.22). Using the final model, only 25.5% (95% CI, 9.3 - 41.6) of participants in the lowest SES tertile were predicted to complete rehabilitation compared to 63.0% (38.4 - 87.6) in the highest SES tertile. Conclusion Lower SES participants with PAH and CTEPH were less likely to complete exercise rehabilitation. Decreased access to effective therapies could account for some of the excess risk seen by lower SES patients with PAH. Policies to enable equity of access to exercise rehabilitation should be explored.