Cost-effectiveness Of Cardiac Rehabilitation Research Articles

Exercise-based cardiac rehabilitation for coronary heart disease: a meta-analysis.

Coronary heart disease is the most common reason for referral to exercise-based cardiac rehabilitation (CR) globally. However, the generalizability of previous meta-analyses of randomized controlled trials (RCTs) is questioned. Therefore, a contemporary updated meta-analysis was undertaken. Database and trial registry searches were conducted to September 2020, seeking RCTs of exercise-based interventions with ≥6-month follow-up, compared with no-exercise control for adults with myocardial infarction, angina pectoris, or following coronary artery bypass graft, or percutaneous coronary intervention. The outcomes of mortality, recurrent clinical events, and health-related quality of life (HRQoL) were pooled using random-effects meta-analysis, and cost-effectiveness data were narratively synthesized. Meta-regression was used to examine effect modification. Study quality was assessed using the Cochrane risk of bias tool. A total of 85 RCTs involving 23 430 participants with a median 12-month follow-up were included. Overall, exercise-based CR was associated with significant risk reductions in cardiovascular mortality [risk ratio (RR): 0.74, 95% confidence interval (CI): 0.64-0.86, number needed to treat (NNT): 37], hospitalizations (RR: 0.77, 95% CI: 0.67-0.89, NNT: 37), and myocardial infarction (RR: 0.82, 95% CI: 0.70-0.96, NNT: 100). There was some evidence of significantly improved HRQoL with CR participation, and CR is cost-effective. There was no significant impact on overall mortality (RR: 0.96, 95% CI: 0.89-1.04), coronary artery bypass graft (RR: 0.96, 95% CI: 0.80-1.15), or percutaneous coronary intervention (RR: 0.84, 95% CI: 0.69-1.02). No significant difference in effects was found across different patient groups, CR delivery models, doses, follow-up, or risk of bias. This review confirms that participation in exercise-based CR by patients with coronary heart disease receiving contemporary medical management reduces cardiovascular mortality, recurrent cardiac events, and hospitalizations and provides additional evidence supporting the improvement in HRQoL and the cost-effectiveness of CR.

Cardiac Rehabilitation Knowledge and Attitudes of Cardiology Fellows.

Cardiac rehabilitation (CR) is underutilized with only 8-31% of eligible patients participating. Lack of referral and lack of physician endorsement are well-known barriers to participation. Physicians who lack insights regarding CR are less likely to refer patients and recommend it. Cardiology fellows are early career physicians who spend a significant amount of time treating patients eligible for CR. At one institution's cardiology fellowship program, we sought to assess fellow attitudes and knowledge base regarding CR and to determine their facilitators and barriers to CR endorsement and referral. University of Pittsburgh Department of Medicine Cardiology fellows were surveyed and interviewed to assess CR knowledge, attitudes, and perceived facilitators and barriers to CR endorsement and referral. The cardiology fellows at this institution had strong belief in the benefits and cost-effectiveness of CR. Despite their support of CR, they had low CR knowledge scores. Perceived impediments to CR included complicated logistics of CR operations, limited communication between CR staff and fellows, limited time with patients, presumed patient barriers, perceived self-barriers, and poor understanding of referral processes (particularly as they varied in each hospital in which they rotated). Perceived supports to CR included greater awareness of evidence-based outcomes, awareness of patient-centered outcomes, pre-arranged order sets, and reminders for referral. This study revealed perceptions of cardiology fellows at one institution regarding CR that have not been considered previously. Key barriers to endorsement and referral to CR were exposed as well as opportunities to overcome them. Fellowship training affords an important opportunity to improve CR education, and to potentially improve participation of eligible patients for this important aspect of care.

Cost-Effectiveness of Cardiac Rehabilitation in Patients with Coronary Artery Disease: A Meta-Analysis.

Background Medical costs associated with cardiovascular disease are increasing considerably worldwide; therefore, an efficacious, cost-effective therapy which allows the effective use of medical resources is vital. There have been few economic evaluations of cardiac rehabilitation (CR), especially meta-analyses of medical cost versus patient outcome. Methods The target population in this meta-analysis included convalescent and comprehensive CR patients with coronary artery disease (CAD), the status most commonly observed postmyocardial infarction (MI). Here, we evaluated medical costs, quality-adjusted life year (QALY), cost-effectiveness, mortality, and life year (LY). Regarding cost-effectiveness analysis, we analyzed medical costs per QALY, medical costs per LY, and the incremental cost-utility ratio (ICUR). We then examined the differences in effects for the 2 treatment arms (CR vs. usual care (UC)) using the risk ratio (RR) and standardized mean difference (SMD). Results We reviewed 59 studies and identified 5 studies that matched our selection criteria. In total, 122,485 patients were included in the analysis. Meta-analysis results revealed that the CR arm significantly improved QALY (SMD: −1.78; 95% confidence interval (CI): −2.69, −0.87) compared with UC. Although medical costs tended to be higher in the CR arm compared to the UC arm (SMD: 0.02; 95% CI: −0.08, 0.13), cost/QALY was significantly improved in the CR arm compared with the UC arm (SMD: −0.31; 95% CI: −0.53, −0.09). The ICURs for the studies (4 RCTs and 1 model analysis) were as follows: −48,327.6 USD/QALY; −5,193.8 USD/QALY (dominant, CR is cheaper and more effective than UC); and 4,048.0 USD/QALY, 17,209.4 USD/QALY, and 26,888.7 USD/QALY (<50,000 USD/QALY, CR is costlier but more effective than UC), respectively. Therefore, there were 2 dominant and 3 effective results. Conclusions While there are some limitations, primarily regarding data sources, our results suggest that CR is potentially cost-effective.

Cardiac rehabilitation: how much pain for the optimal gain?

Cardiac rehabilitation: how much pain for the optimal gain?

Cardiac rehabilitation: Providing a high-quality service

British Journal of Cardiac NursingVol. 6, No. 2 Policy UpdateCardiac rehabilitation: Providing a high-quality serviceMichelle Bull, Patrick DohertyMichelle BullSearch for more papers by this author, Patrick DohertySearch for more papers by this authorMichelle Bull; Patrick DohertyPublished Online:27 Sep 2013https://doi.org/10.12968/bjca.2011.6.2.80AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References British Association for Cardiac Rehabilitation (2007) Standards and Core Components for Cardiac Rehabilitation (2007). http://tinyurl.com/3ydagw (accessed 27 January 2011) Google ScholarBritish Heart Foundation (2008) The National Audit of Cardiac Rehabilitation: Annual Statistical Report 2008. http://www.cardiacrehabilitation.org.uk/nacr/docs/2008.pdf (accessed 25 January 2011) Google ScholarBritish Heart Foundation (2010a) The National Audit of Cardiac Rehabilitation: Annual Statistical Report 2010. http://www.cardiacrehabilitation.org.uk/nacr/docs/2010.pdf (accessed 25 January 2011) Google ScholarBritish Heart Foundation (2010b) What Should I Expect from Cardiac Rehabilitation? A guide for Heart Patients in England. [Booklet G157] http://tinyurl.com/4usbavu (accessed 25 January 2011) Google ScholarDalal H, Zawada Jolly K, Moxham T, Taylor RS (2010) Home based versus centre based cardiac rehabilitation. BMJ 340: b5631. Crossref, Google ScholarDepartment of Health (2000) National Service Framework for Coronary Heart Disease. Chapter Seven: Cardiac Rehabilitation. DH, London. Google ScholarDepartment of Health (2010a) Strategic commissioning development unit (SCDU) Commissioning Packs. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_117500 (accessed 25 January 2011) Google ScholarDepartment of Health (2010b) The NHS Outcomes Framework 2011/12. DH, London Google ScholarDepartment of Health (2010c) Equity and Excellence: Liberating the NHS. DH, London Google ScholarJolliffe J, Rees K, Taylor RRS, Thompson DR, Oldridge N and S. Ebrahim (2001) Exercise-based rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2001: CD001800 Google ScholarNHS Improvement (2010) National Cardiac Rehabilitation Projects 2010–2011. http://www.improvement.nhs.uk/heart/National_Cardiac_Rehabilitation_projects/tabid/117/Default.aspx (accessed 25 January 2011) Google ScholarNHS Improvement Heart (2010) Transforming Cardiac Rehabilitation: Celebrating Achievements and Sharing the Learning from the National Projects. http://www.improvement.nhs.uk/documents/Transforming_Cardiac_Rehab.pdf (accessed 26 January 2011) Google ScholarStrategic Commissioning Development Unit (2010). Commissioning a Cardiac Rehabilitation Service. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_117504 (accessed 25 January 2011) Google ScholarTaylor R, Kirby B (1997) The evidence base for the cost effectiveness of cardiac rehabilitation. Heart 78(1): 5–6 Crossref, Google Scholar FiguresReferencesRelatedDetails 1 February 2011Volume 6Issue 2ISSN (online): 2052-2207 Metrics History Published online 27 September 2013 Published in print 1 February 2011 Information© MA Healthcare LimitedPDF download

Analyses of Studies on Cardiac Rehabilitation for Patients with Cardiovascular Disease in Korea

This study was to analyze research reports published in Korea on cardiac rehabilitation for patients with cardiovascular disease. Based on inclusion criteria, 19 research reports were included in this review. Published year of selected articles was between 1996 and 2008. Nineteen studies were analyzed by guidelines of the cardiac rehabilitation programs done by the American Heart Association (AHA) and Scottish Intercollegiate Guidelines Network (SIGN). The characteristics of patients were mostly of ischemic heart disease, 50-59 yr old, and male. Educational sessions were administered twice, and each lesson lasted less than 30 min. Exercise was done 3 times per week for 6 weeks. Most educational content were about risk factors, but there was no information, such as coping with feelings. Most exercise was performed as ROM, treadmill, and cycle ergometer. A large percentage of outcome indicators were health behavior, hemodynamic changes, and exercise capacity. There was more 'no effect' than 'positive effect' in trait anxiety and depression, whereas similar in physiologic domain. Various types of cardiac rehabilitation in Korea were performed by researchers. Therefore, we need to develop the standard protocol, to add psychosocial intervention, and to study cost effectiveness of cardiac rehabilitation.

Community or patient preferences for cost-effectiveness of cardiac rehabilitation: does it matter?

Few healthcare economic evaluations, and none in cardiac rehabilitation, report results based on both community and patient preferences for health outcomes. We published the results of a randomized trial of cardiac rehabilitation after myocardial infarction in 1994 in which preferences were measured using both perspectives but only patient preferences were reported. This secondary analysis uses both types of preference measurements. We collected community Quality of Well-Being (QWB) and patient Time Trade-off (TTO) preference scores from 188 patients (rehabilitation, n=93; usual care, n=95) on entry into the trial, at 2 months (end of the intervention) and again at 4, 8, and 12 months. Mean preference scores over the 12-month follow-up study period, estimates of quality-adjusted life years (QALYs) gained per patient, incremental cost-effectiveness ratios [costs inflated to 2006 US dollars] and probabilities of the cost-effectiveness of rehabilitation for costs per QALY up to USD100,000 are reported. Mean QWB preference scores were lower (P<0.01) than the corresponding mean TTO preference scores at each assessment point. The 12-month changes in mean QWB and TTO preference scores were large and positive (P<0.001) with rehabilitation patients gaining a mean of 0.011 (95% confidence interval, -0.030 to +0.052) more QWB-derived QALYs, and 0.040 (-0.026, 0.107) more TTO-derived QALYs, per patient than usual care patients. The incremental cost-effectiveness ratio for QWB-derived QALYs was estimated at $60 270/QALY (about euro50 600/QALY) and at $16 580/QALY (about euro13 900/QALY) with TTO-derived QALYs. With a willingness to spend $100 000/QALY, the probability of rehabilitation being cost-effective is 0.58 for QWB-derived QALYs and 0.83 for TTO-derived QALYs. This secondary analysis of data from a randomized trial indicates that cardiac rehabilitation is cost-effective from a community perspective and highly cost-effective from the perspective of patients.

Universal access: But when? Treating the right patient at the right time: Access to cardiac rehabilitation

The Canadian Cardiovascular Society formed an Access to Care Working Group ('Working Group') in the spring of 2004. The mandate of the group was to use the best science and information to establish reasonable triage categories and safe wait times for access to common cardiovascular services and procedures. The present commentary presents the rationale for benchmarks for cardiac rehabilitation (CR) services. The Working Group's search for evidence included: a full literature review of the efficacy of CR, and the factors affecting access and referral to CR; a review of existing guidelines for access to CR; and a national survey of 14 CR programs across Canada undertaken in May 2005 to solicit information on referral to, and wait times for, CR. The Working Group also reviewed the results of The Ontario Cardiac Rehabilitation Pilot Project (2002) undertaken by the Cardiac Care Network of Ontario, which reported the average and median wait times for CR. Some international agencies have formulated their own guidelines relating to the optimal wait time for the onset of CR. However, due to the limited amount of supporting literature, these guidelines have generally been formed as consensus statements. The Canadian national survey showed that few programs had guidelines for individual programs. The Cardiac Care Network of Ontario pilot project reported that the average and median times from a cardiac event to the intake into CR were 99 and 70 days, respectively. The national survey of sampled CR programs also revealed quite remarkable differences across programs in terms of the length of time between first contact to first attendance and to commencement of exercise. Programs that required a stress test before program initiation had the longest wait for exercise initiation. Some patients need to be seen within a very short time frame to prevent a marked deterioration in their medical or psychological state. In some cases, early intervention and advocacy may reduce the risk of loss of employment. Or, there may be profound disturbances in the patient's family as a result of the cardiac event. For other patient groups, preferable wait times vary from one to 30 days, and acceptable wait times vary from seven to 60 days. All cardiovascular disease patients require core aspects of CR services. Patients who would derive benefit from formal CR programs should be provided the opportunity, given the proven efficacy and cost effectiveness of CR.

Cost-Effectiveness of Cardiac Rehabilitation After Myocardial Infarction

Cardiac rehabilitation is commonly prescribed after myocardial infarction (MI) to coordinate exercise training and secondary preventive services. Cost-effectiveness analysis allows the quantitative comparison of the relative economic worth of cardiac rehabilitation in relation to other common interventions. The cost-effectiveness of cardiac rehabilitation, in dollars per year of life saved ($/YLS), was calculated by combining published results of randomized trials of cardiac rehabilitation on mortality rates, epidemiologic studies of long-term survival in the overall postinfarction population, and studies of patient charges for rehabilitation services and averted medical expenses for hospitalizations after rehabilitation. Cardiac rehabilitation participants experienced an incremental life expectancy of 0.202 years during a 15-year period. In 1988, the average cost of rehabilitation and exercise testing was $1,485, partially offset by averted cardiac rehospitalizations of $850 per patient. A cost-effectiveness value of 2,130 $/YLS was determined for the late 1980s, projected to a value of 4,950 $/YLS for 1995. A sensitivity analysis supports the study results. Compared with other post-MI treatment interventions, cardiac rehabilitation is more cost-effective than thrombolytic therapy, coronary bypass surgery, and cholesterol lowering drugs, though less cost-effective than smoking cessation programs. Cardiac rehabilitation should stand alongside these therapies as standard of care in the post-MI setting.