Original articleOptimizing Value From Cardiac Rehabilitation: A Cost-Utility Analysis Comparing Age, Sex, and Clinical Subgroups
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
References (31)
Lifestyle modification interventions and cardiovascular health: global perspectives on worksite health and wellness and cardiac rehabilitation
Prog Cardiovasc Dis
(2014)- et al.
Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials
Am J Med
(2004) Probabilistic analysis of cost-effectiveness models: statistical representation of parameter uncertainty
Value Health
(2005)- et al.
Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction
Am J Cardiol
(1993) - et al.
A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention
Arch Phys Med Rehabil
(2004) - et al.
Cardiac rehabilitation in the United States
Prog Cardiovasc Dis
(2014) - et al.
Cardiac rehabilitation series: Canada
Prog Cardiovasc Dis
(2014) - et al.
Cardiac rehabilitation and risk reduction: time to “rebrand and reinvigorate.”
J Am Coll Cardiol
(2015) - et al.
Cardiovascular fitness and mortality after contemporary cardiac rehabilitation
Mayo Clinic Proc
(2013) - et al.
Exercise-based cardiac rehabilitation and improvements in cardiorespiratory fitness: implications regarding patient benefit
Mayo Clinic Proc
(2013)
Exercise-based cardiac rehabilitation for coronary heart disease
Cochrane Database Syst Rev
What Is Cardiac Rehabilitation?
Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: a systematic review and meta-analysis of randomized controlled trials
Am Heart J
A systematic review of economic evaluations of cardiac rehabilitation
BMC Health Serv Res
Cost-utility analysis
BMJ
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Grant Support: This research was supported by grant 856 from the M.S.I. Foundation.