EU-CaRE study: Could exercise-based cardiac telerehabilitation also be cost-effective in elderly?

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Highlights

  • Home-based cardiac rehabilitation is a feasible solution in elderly

  • The healthcare utilisation costs (P = 0.802) were not significantly different between the two groups

  • The ICER for the primary endpoint VO2peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO2peak

  • Big differences in ICER were present between the adherent participants and the non-adherent participants.

Abstract

Background

The role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease. Unfortunately, the participation rates across Europe remain low, especially in elderly. The EU-CaRE RCT investigated the effectiveness of a home-based mobile CR programme in elderly patients that were not willing to participate in centre-based CR. The initial study concluded that a 6-month home-based mobile CR programme was safe and beneficial in improving VO2peak when compared with no CR.

Objective

To assess whether a 6-month guided mobile CR programme is a cost-effective therapy for elderly patients who decline participation in CR.

Methods

Patients were enrolled in a multicentre randomised clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. A total of 179 patients who declined participation in centre-based CR and met the inclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programs in the Elderly trial. The data of patients (n = 17) that were lost in follow-up were excluded from this analysis.

The intervention (n = 79) consisted of 6 months of mobile CR programme with telemonitoring, and coaching based on motivational interviewing to stimulate patients to reach exercise goals. Control patients did not receive any form of CR throughout the study period. The costs considered for the cost-effectiveness analysis of the RCT are direct costs 1) of the mobile CR programme, and 2) of the care utilisation recorded during the observation time from randomisation to the end of the study. Costs and outcomes (utilities) were compared by calculation of the incremental cost-effectiveness ratio.

Results

The healthcare utilisation costs (P = 0.802) were not significantly different between the two groups. However, the total costs were significantly higher in the intervention group (P = 0.040). The incremental cost-effectiveness ratio for the primary endpoint VO2peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO2peak and at 12 months it was €1103 per 1 unit [ml/kg/min] improvement in change VO2peak. Big differences in the incremental cost-effectiveness ratios for the primary endpoint VO2peak at 6 months and 12 months were present between the adherent participants and the non-adherent participants.

Conclusion

From a health-economic point of view the home-based mobile CR programme is an effective and cost-effective alternative for elderly cardiac patients who are not willing to participate in a regular rehabilitation programme to improve cardiorespiratory fitness. The change of QoL between the mobile CR was similar for both groups. Adherence to the mobile CR programme plays a significant role in the cost-effectiveness of the intervention. Future research should focus on the determinants of adherence, on increasing the adherence of patients and the implementation of comprehensive home-based mobile CR programmes in standard care.

Introduction

The role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease (IHD) [[1], [2], [3], [4]]. Multiple studies have demonstrated the effectiveness and cost-effectiveness of CR in reducing morbidity and mortality along with increasing quality of life (QoL) and psychological well-being [[1], [2], [3], [4]]. Unfortunately, the latest EUROASPIRE survey revealed that still only few of the eligible IHD patients participate in phase II CR [5]. Multiple reasons are stated for the low participation rates such as lower health literacy or transport, familial, vocational, and schedule constraints [6,7]. The participation rates are even worse for elderly patients, despite their higher prevalence of comorbidities and a less physically active lifestyle [8]. Therefore, home-based mobile CR programmes have been researched as an alternative. However, many fear that this will leave out elderly who are often less digitally literate. Telerehabilitation or mobile CR programme is defined as the use of digital tools to deliver the core components of CR from a distance. It allows remote monitoring of patients and the provision of objective feedback to those patients who are unable or not willing to participate in centre-based CR programmes. Numerous studies have demonstrated that mobile CR programmes are as effective as centre-based CR in terms of exercise capacity and QoL [[9], [10], [11], [12]]. A recent systematic review concluded that, based on small and short duration trials, the mobile CR programme seems to be as cost-effective as centre-based CR programmes [13]. The EU-CaRE RCT researched the effectiveness of a mobile CR programme in elderly patients that were not willing to participate in center-based CR [14]. Snoek et al. revealed that a 6-month home-based mobile CR programme focusing on exercise was safe and beneficial in improving VO2peak when compared with no CR [14]. With this EU-CaRE RCT follow-up study, we assessed whether the 6-month home-based mobile CR programme was cost-efficient in comparison with no CR.

Section snippets

Study design

The European study on effectiveness and sustainability of current CR programmes in the Elderly (EU-CaRE) is an international multicentre parallel RCT. The study was conducted in accordance with the applicable legislation and guidelines. Six European cardiac institutions across five European countries participated in the EU-CaRE RCT: Isala Heart Centre (The Netherlands), Bispebjerg University Hospital, Copenhagen, Denmark (Denmark), Assistance Publique – Hôpitaux de Paris (France), Bern

Baseline characteristics

In total, 162 patients were included in the analysis. The data of 17 patients that were lost in follow-up were excluded from this analysis. Only 26% of eligible patients who declined centre-based CR participated decided to take part in the present study.

The patients in the intervention group (n = 79) had a mean age of 72.3 years and were predominantly men (85.5%). The patients in the control group (n = 83) had a mean age of 73.3 years and were predominantly men (78.5%). Only the presence of

Discussion

In elderly cardiac patients not willing to participate in a regular rehabilitation programme, the mobile CR programme was effective in improving VO2peak between both baseline and the end of the 6-month mobile CR programme and between baseline and the end of the follow-up after 12 months at reasonably low cost. The intervention was more cost-effective in patients who were adherent to the mobile CR programme.

The costs of care utilisation showed a non-significant decrease in the intervention group

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was funded by the European Union's Horizon 2020 research and innovation programme under grant agreement No 634439. For the Swiss consortium partner, funding was received by the Swiss State Secretariat for Education, Research and Innovation under contract number 15.0139. TM, PE and MW report grants from State Secretariat for Education, Research and

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