Cost-effectiveness of Cardiac Telerehabilitation With Relapse Prevention for the Treatment of Patients With Coronary Artery Disease in the Netherlands

Abstract

Importance: Cardiac telerehabilitation (CTR) has been found to be a safe and beneficial alternative to traditional center-based cardiac rehabilitation (CR) and might be associated with higher participation rates by reducing barriers to CR use. However, implementation of CTR interventions remains low, which may be owing to a lack of cost-effectiveness analyses of data from large-scale randomized clinical trials.

Objective: To assess the cost-effectiveness of CTR with relapse prevention compared with center-based CR among patients with coronary artery disease.

Design, setting, and participants: This economic evaluation performed a cost-utility analysis of data from the SmartCare-CAD (Effects of Cardiac Telerehabilitation in Patients With Coronary Artery Disease Using a Personalized Patient-Centred ICT Platform) randomized clinical trial. The cost-effectiveness and utility of 3 months of cardiac telerehabilitation followed by 9 months of relapse prevention were compared with the cost-effectiveness of traditional center-based cardiac rehabilitation. The analysis included 300 patients with stable coronary artery disease who received care at a CR center serving 2 general hospitals in the Netherlands between May 23, 2016, and July 26, 2018. All patients were entering phase 2 of outpatient CR and were followed up for 1 year (until August 14, 2019). Data were analyzed from September 21, 2020, to September 24, 2021.

Intervention: After baseline measurements were obtained, participants were randomly assigned on a 1:1 ratio to receive CTR (intervention group) or center-based CR (control group) using computerized block randomization. After 6 supervised center-based training sessions, patients in the intervention group continued training at home using a heart rate monitor and accelerometer. Patients uploaded heart rate and physical activity data and discussed their progress during a weekly video consultation with their physical therapist. After 3 months, weekly coaching was concluded, and on-demand coaching was initiated for relapse prevention; patients were instructed to continue using their wearable sensors and were contacted in cases of nonadherence to the intervention or reduced exercise or physical activity volumes.

Main outcomes and measures: Quality-adjusted life-years were assessed using the EuroQol 5-Dimension 5-Level survey (EQ-5D-5L) and the EuroQol Visual Analogue Scale (EQ-VAS), and cardiac-associated health care costs and non-health care costs were measured by health care consumption, productivity, and informal care questionnaires (the Medical Consumption Questionnaire, the Productivity Cost Questionnaire, and the Valuation of Informal Care Questionnaire) designed by the Institute for Medical Technology Assessment. Costs were converted to 2020 price levels (in euros) using the Dutch consumer price index (to convert to US dollars, euro values were multiplied by 1.142, which was the mean exchange rate in 2020).

Results: Among 300 patients (266 men [88.7%]), the mean (SD) age was 60.7 (9.5) years. The quality of life among patients receiving CTR vs center-based CR was comparable during the study according to the results of both utility measures (mean difference on EQ-5D-5L: -0.004; P = .82; mean difference on EQ-VAS: -0.001; P = .92). Intervention costs were significantly higher for CTR (mean [SE], €224 [€4] [$256 ($4)]) compared with center-based CR (mean [SE], €156 [€5] [$178 ($6)]; P < .001); however, no difference in overall cardiac health care costs was observed between CTR (mean [SE], €4787 [€503] [$5467 ($574)] and center-based CR (mean [SE], €5507 [€659] [$6289 ($753)]; P = .36). From a societal perspective, CTR was associated with lower costs compared with center-based CR (mean [SE], €20 495 [€ 2751] [$23 405 ($3142)] vs €24 381 [€3613] [$27 843 ($4126)], respectively), although this difference was not statistically significant (-€3887 [-$4439]; P = .34).

Conclusions and relevance: In this economic evaluation, a CTR intervention with relapse prevention was likely to be cost-effective compared with center-based CR, suggesting that CTR maybe used as an alternative intervention for the treatment of patients with coronary artery disease. These results add to the evidence base in favor of CTR and may increase the implementation of CTR interventions in clinical practice.

Figure 1.. Modified CONSORT Diagram of Participants in the SmartCare-CAD Clinical Trial

CR indicates cardiac rehabilitation; CTR, cardiac telerehabilitation; and SmartCare-CAD, Effects of Cardiac Telerehabilitation in Patients With Coronary Artery Disease Using a Personalized Patient-Centred ICT Platform.

Figure 2.. Utilities for Cardiac Telerehabilitation and Center-Based Cardiac Rehabilitation

Utilities according to the Dutch versions of the EuroQol 5-Dimension 5-Level survey (EQ-5D-5L) and the EuroQol Visual Analogue Scale (EQ-VAS). CR indicates cardiac rehabilitation; CTR, cardiac telerehabilitation.

Figure 3.. Cost-effectiveness Plane for Base-Case Analysis and Cost-effectiveness Acceptability Curves

A, The cost-effectiveness plane for the base-case analysis included cardiac-associated health care costs, non–health care costs according to the friction cost method (FCM), and quality of life (QOL) measures from the EuroQol 5-Dimension 5-Level survey (EQ-5D-5L). To convert to US dollars, multiply by 1.142, the mean exchange rate in 2020 (eg, €5000 is equivalent to $5710, €10 000 is equivalent to $11 420, €15 000 is equivalent to $17 130, and €20 000 is equivalent to $22 840). B, The base-case analysis included cardiac-associated health care costs, non–health care costs according to the FCM, and QOL measures from the EQ-5D-5L. Sensitivity analysis 1 included cardiac-associated health care costs and QOL measures from the EQ-5D-5L. Sensitivity analysis 2 included cardiac-associated health care, non–health care costs according to the FCM, and utility measures from the EuroQol Visual Analogue Scale. Sensitivity analysis 3 included cardiac-associated health care costs, productivity costs according to the human capital method, and QOL measures from the EQ-5D-5L. Sensitivity analysis 4 included total health care costs, non–health care costs according to the FCM, and QOL measures from the EQ-5D-5L. The dashed horizontal line at 50% probability represents the point at which no preference for either strategy (center-based cardiac rehabilitation [CR] or cardiac telerehabilitation [CTR]) exists. To convert to US dollars, multiply by 1.142, the mean exchange rate in 2020 (eg, €50 000 is equivalent to $57 100, €100 000 is equivalent to $114 200, €150 000 is equivalent to $171 300, and €200 000 is equivalent to $228 400).