Elsevier

Mayo Clinic Proceedings

Volume 90, Issue 8, August 2015, Pages 1011-1020
Mayo Clinic Proceedings

Original article
Optimizing Value From Cardiac Rehabilitation: A Cost-Utility Analysis Comparing Age, Sex, and Clinical Subgroups

https://doi.org/10.1016/j.mayocp.2015.05.015Get rights and content

Abstract

Objective

To assess the cost utility of a center-based outpatient cardiac rehabilitation program compared with no program within patient subgroups on the basis of age, sex, and clinical presentation (acute coronary syndrome [ACS] or non-ACS).

Methods

We performed a cost-utility analysis from a health system payer perspective to compare cardiac rehabilitation with no cardiac rehabilitation for patients who had a cardiac catheterization. The Markov model was stratified by clinical presentation, age, and sex. Clinical, quality-of-life, and cost data were provided by the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology.

Results

The incremental cost per quality-adjusted life-year (QALY) gained for cardiac rehabilitation varies by subgroup, from $18,101 per QALY gained to $104,518 per QALY gained. There is uncertainty in the estimates due to uncertainty in the clinical effectiveness of cardiac rehabilitation. Overall, the probabilistic sensitivity analysis found that 75% of the time participation in cardiac rehabilitation is more expensive but more effective than not participating in cardiac rehabilitation.

Conclusion

The cost-effectiveness of cardiac rehabilitation varies depending on patient characteristics. The current analysis indicates that cardiac rehabilitation is most cost effective for those with an ACS and those who are at higher risk for subsequent cardiac events. The findings of the current study provide insight into who may benefit most from cardiac rehabilitation, with important implications for patient referral patterns.

Section snippets

Study Design

The cost per QALY gained was the primary outcome. A Markov model compared center-based outpatient cardiac rehabilitation (hereafter referred to as cardiac rehabilitation) vs no cardiac rehabilitation for patients who have undergone a cardiac catheterization (Figure 1). A cycle length of 1 year was used. The model was stratified by age (<65, 65-74, >75 years), clinical presentation (with or without ACS), and sex to capture the differential risks of clinical events across the patient population.

Risk of Death and Second Event

The probability of death and the probability of having a second cardiac event in the year after cardiac catheterization were calculated for each age, sex, and clinical presentation subgroup, using the APPROACH database. A second event was defined as any percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or catheterization completed between 90 and 365 days after the index catheterization. Kaplan-Meier survival analysis was used to calculate the long-term annual risk

Model Validity

The validity of the decision model was assessed in accordance with published guidelines.9 Technical accuracy and internal validity was assessed by systematically modifying each input using extreme and null values to ensure the model was responding properly. Outcomes were assessed for external validity by comparing the costs per QALY found in this analysis with the costs per QALY reported in existing cost-utility analyses.17, 18

Patient Cohort

The clinical inputs were calculated using a cohort of myocardial

Discussion

We found that cardiac rehabilitation resulted in greater cost but improved clinical outcomes compared with no cardiac rehabilitation for patients who have undergone cardiac catheterization. Considering a health system payer perspective, the overall cost per QALY gained associated with cardiac rehabilitation was $37,662. Among the subgroups assessed in the current study, this cost varied widely: from $18,102 to $104,519 per QALY gained, depending on age, clinical presentation and sex. Broadly,

Conclusion

Cardiac rehabilitation appears to be an economically attractive intervention for individuals who have had a cardiac event. The cost per QALY of cardiac rehabilitation is in line with other technologies that are funded within many health care systems. Our findings particularly support the use of cardiac rehabilitation for those older than 75 years and those with ACS. Although reasonable value for money, this intervention does not save costs and does represent an opportunity cost. The provision

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    Grant Support: This research was supported by grant 856 from the M.S.I. Foundation.

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