A systematic review of economic evaluations of cardiac rehabilitation

Wai Pong Wong, Jun Feng, Keng Ho Pwee, Jeremy Lim, Wai Pong Wong, Jun Feng, Keng Ho Pwee, Jeremy Lim

Abstract

Background: Cardiac rehabilitation (CR), a multidisciplinary program consisting of exercise, risk factor modification and psychosocial intervention, forms an integral part of managing patients after myocardial infarction (MI), revascularization surgery and percutaneous coronary interventions, as well as patients with heart failure (HF). This systematic review seeks to examine the cost-effectiveness of CR for patients with MI or HF and inform policy makers in Singapore on published cost-effectiveness studies on CR.

Methods: Electronic databases (EMBASE, MEDLINE, NHS EED, PEDro, CINAHL) were searched from inception to May 2010 for published economic studies. Additional references were identified through searching bibliographies of included studies. Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Quality assessment of economic evaluations was undertaken using Drummond's checklist.

Results: A total of 22 articles were selected for review. However five articles were further excluded because they were cost-minimization analyses, whilst one included patients with stroke. Of the final 16 articles, one article addressed both centre-based cardiac rehabilitation versus no rehabilitation, as well as home-based cardiac rehabilitation versus no rehabilitation. Therefore, nine studies compared cost-effectiveness between centre-based supervised CR and no CR; three studies examined that between centre- and home based CR; one between inpatient and outpatient CR; and four between home-based CR and no CR. These studies were characterized by differences in the study perspectives, economic study designs and time frames, as well as variability in clinical data and assumptions made on costs. Overall, the studies suggested that: (1) supervised centre-based CR was highly cost-effective and the dominant strategy when compared to no CR; (2) home-based CR was no different from centre-based CR; (3) no difference existed between inpatient and outpatient CR; and (4) home-based programs were generally cost-saving compared to no CR.

Conclusions: Overall, all the studies supported the implementation of CR for MI and HF. However, comparison across studies highlighted wide variability of CR program design and delivery. Policy makers need to exercise caution when generalizing these findings to the Singapore context.

Figures

Figure 1
Figure 1
Flow of included studies.

References

    1. Yusuf S, Reddy S, Ounpuu S, Anand S. Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001;104(22):2746–2753. doi: 10.1161/hc4601.099487.
    1. Levenson JW, Skerrett PJ, Gaziano JM. Reducing the global burden of cardiovascular disease: the role of risk factors. Prev Cardiol. 2002;5(4):188–199. doi: 10.1111/j.1520-037X.2002.00564.x.
    1. Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA, Certo CME, Dattilo AM, Davis D, DeBusk RF, Cardiac Rehabilitation. Clinical Practice Guideline No. 17. U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Rockville, MD; 1995.
    1. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM, Franklin B, Sanderson B, Southard D. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115(20):2675–2682. doi: 10.1161/CIRCULATIONAHA.106.180945.
    1. Dafoe W, Arthur H, Stokes H, Morrin L, Beaton L. Universal access: but when? Treating the right patient at the right time: access to cardiac rehabilitation. Can J Cardiol. 2006;22(11):905–911. doi: 10.1016/S0828-282X(06)70309-9.
    1. O'Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS, Hennekens CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation. 1989;80(2):234–244. doi: 10.1161/01.CIR.80.2.234.
    1. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA. 1988;260(7):945–950. doi: 10.1001/jama.1988.03410070073031.
    1. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004;116(10):682–692. doi: 10.1016/j.amjmed.2004.01.009.
    1. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;7:CD001800.
    1. Papadakis S, Oldridge NB, Coyle D, Mayhew A, Reid RD, Beaton L, Dafoe WA, Angus D. Economic evaluation of cardiac rehabilitation: a systematic review. Eur J Cardiovasc Prev Rehabil. 2005;12(6):513–520.
    1. Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. 3. Oxford University Press, New York; 2005.
    1. Levin LA, Perk J, Hedback B. Cardiac rehabilitation–a cost analysis. J Intern Med. 1991;230(5):427–434. doi: 10.1111/j.1365-2796.1991.tb00468.x.
    1. Ades PA, Huang D, Weaver SO. Cardiac rehabilitation participation predicts lower rehospitalization costs. Am Heart J. 1992;123(4 Pt 1):916–921.
    1. Oldridge N, Furlong W, Feeny D, Torrance G, Guyatt G, Crowe J, Jones N. Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction. Am J Cardiol. 1993;72(2):154–161. doi: 10.1016/0002-9149(93)90152-3.
    1. Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil. 1997;17(4):222–231. doi: 10.1097/00008483-199707000-00002.
    1. Georgiou D, Chen Y, Appadoo S, Belardinelli R, Greene R, Parides MK, Glied S. Cost-effectiveness analysis of long-term moderate exercise training in chronic heart failure. Am J Cardiol. 2001;87(8):984–988. doi: 10.1016/S0002-9149(01)01434-5. A984.
    1. Marchionni N, Fattirolli F, Fumagalli S, Oldridge N, Del Lungo F, Morosi L, Burgisser C, Masotti G. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial. Circulation. 2003;107(17):2201–2206. doi: 10.1161/01.CIR.0000066322.21016.4A.
    1. Yu CM, Lau CP, Chau J, McGhee S, Kong SL, Cheung BM, Li LS. A short course of cardiac rehabilitation programme 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;85(12):1915–1922. doi: 10.1016/j.apmr.2004.05.010.
    1. Huang Y, Zhang R, Culler SD, Kutner NG. Costs and effectiveness of cardiac rehabilitation for dialysis patients following coronary bypass. Kidney Int. 2008;74(8):1079–1084. doi: 10.1038/ki.2008.381.
    1. Dendale P, Hansen D, Berger J, Lamotte M. Long-term cost-benefit ratio of cardiac rehabilitation after percutaneous coronary intervention. Acta Cardiol. 2008;63(4):451–456. doi: 10.2143/AC.63.4.2033043.
    1. DeBusk RF, Haskell WL, Miller NH, Berra K, Taylor CB, Berger WE, Lew H. Medically directed at-home rehabilitation soon after clinically uncomplicated acute myocardial infarction: a new model for patient care. Am J Cardiol. 1985;55(4):251–257. doi: 10.1016/0002-9149(85)90355-8.
    1. Lowensteyn I, Coupal L, Zowall H, Grover SA. The cost-effectiveness of exercise training for the primary and secondary prevention of cardiovascular disease. J Cardiopulm Rehabil. 2000;20(3):147–155. doi: 10.1097/00008483-200005000-00002.
    1. Carlson JJ, Johnson JA, Franklin BA, VanderLaan RL. Program participation, exercise adherence, cardiovascular outcomes, and program cost of traditional versus modified cardiac rehabilitation. Am J Cardiol. 2000;86(1):17–23. doi: 10.1016/S0002-9149(00)00822-5.
    1. Collins L, Scuffham P, Gargett S. Cost-analysis of gym-based versus home-based cardiac rehabilitation programs. Aust Health Rev. 2001;24(1):51–61. doi: 10.1071/AH010051.
    1. Reid RD, Dafoe WA, Morrin L, Mayhew A, Papadakis S, Beaton L, Oldridge NB, Coyle D, Wells GA. Impact of program duration and contact frequency on efficacy and cost of cardiac rehabilitation: results of a randomized trial. Am Heart J. 2005;149(5):862–868. doi: 10.1016/j.ahj.2004.09.029.
    1. Taylor RS, Watt A, Dalal HM, Evans PH, Campbell JL, Read KL, Mourant AJ, Wingham J, Thompson DR, Pereira Gray DJ. Home-based cardiac rehabilitation versus hospital-based rehabilitation: a cost effectiveness analysis. Int J Cardiol. 2007;119(2):196–201. doi: 10.1016/j.ijcard.2006.07.218.
    1. Papadakis S, Reid RD, Coyle D, Beaton L, Angus D, Oldridge N. Cost-effectiveness of cardiac rehabilitation program delivery models in patients at varying cardiac risk, reason for referral, and sex. Eur J Cardiovasc Prev Rehabil. 2008;15(3):347–353. doi: 10.1097/HJR.0b013e3282f5ffab.
    1. Jolly K, Lip GY, Taylor RS, Raftery J, Mant J, Lane D, Greenfield S, Stevens A. The Birmingham Rehabilitation Uptake Maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation. Heart. 2009;95(1):36–42.
    1. Schweikert B, Hahmann H, Steinacker JM, Imhof A, Muche R, Koenig W, Liu Y, Leidl R. Intervention study shows outpatient cardiac rehabilitation to be economically at least as attractive as inpatient rehabilitation. Clin Res Cardiol. 2009;98(12):787–795. doi: 10.1007/s00392-009-0081-6.
    1. Wheeler JR, Janz NK, Dodge JA. Can a disease self-management program reduce health care costs? The case of older women with heart disease. Med Care. 2003;41(6):706–715.
    1. Southard BH, Southard DR, Nuckolls J. Clinical trial of an Internet-based case management system for secondary prevention of heart disease. J Cardiopulm Rehabil. 2003;23(5):341–348. doi: 10.1097/00008483-200309000-00003.
    1. Salvetti XM, Oliveira JA, Servantes DM, Vincenzo de Paola AA. How much do the benefits cost? Effects of a home-based training programme on cardiovascular fitness, quality of life, programme cost and adherence for patients with coronary disease. Clin Rehabil. 2008;22(10–11):987–996.
    1. Hall JP, Wiseman VL, King MT, Ross DL, Kovoor P, Zecchin RP, Moir FM, Denniss AR. Economic evaluation of a randomised trial of early return to normal activities versus cardiac rehabilitation after acute myocardial infarction. Heart Lung Circ. 2002;11(1):10–18. doi: 10.1046/j.1444-2892.2002.00105.x.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa