Cost-effectiveness of cardiac telerehabilitation with relapse prevention for the treatment of patients with coronary artery disease in the Netherlands

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 centerbased 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 costeffectiveness 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], (sic)224 [(sic)4] [$256 ($4)]) compared with center-based CR (mean [SE], (sic)156 [(sic)5] [$178 ($6)]; P <.001); however, no difference in overall cardiac health care costs was observed between CTR (mean [SE], (sic)4787 [(sic)503] [$5467 ($574)] and center-based CR (mean [SE], (sic)5507 [(sic)659] [$6289 ($753)]; P =.36). From a societal perspective, CTR was associated with lower costs compared with center-based CR (mean [SE], (sic)20 495 [(sic)2751] [$23 405 ($3142)] vs (sic)24 381 [(sic)3613] [$27 843 ($4126)], respectively), although this difference was not statistically significant (-(sic)3887 [-$ 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.Analysis and support of clinical decision makin

Recommendations on how to provide cardiac rehabilitation services during the COVID-19 pandemic

The ongoing coronavirus disease 2019 (COVID-19) crisis is having a large impact on acute and chronic cardiac care. Due to public health measures and the reorganisation of outpatient cardiac care, traditional centre-based cardiac rehabilitation is currently almost impossible. In addition, public health measures are having a potentially negative impact on lifestyle behaviour and general well-being. Therefore, the Working Group of Cardiovascular Prevention and Rehabilitation of the Dutch Society of Cardiology has formulated practical recommendations for the provision of cardiac rehabilitation during the COVID-19 pandemic, by using telerehabilitation programmes without face-to-face contact based on current guidelines supplemented with new insights and experiences.</p

Evaluation of an application for the self-assessment of lifestyle behaviour in cardiac patients

BackgroundCurrently, no uniform, well-validated and comprehensive lifestyle behaviour self-assessment instrument exists for patients with cardiovascular disease.PurposeTo evaluate the usability of a novel mobile application (LifeStyleScore) based on validated instruments for the assessment of cardiovascular risk behaviours. Secondly, the application’s acceptance by healthcare professionals (HCPs) and its association with improved patient activation and lifestyle behaviour was evaluated.MethodsIn this single-centre, non-randomised observational pilot study, patients with coronary artery disease or atrial fibrillation entering cardiac rehabilitation (CR) completed the LifeStyleScore application, the Patient Activation Measure (PAM-13®), and the System Usability Scale (SUS) during the CR intake and after CR completion. A focus group interview was performed with the HCPs involved.ResultsWe analysed 20 participants, 3 of whom were women, with a mean age of 61.9 ± 6.7 years. The LifeStyleScore application was rated with a SUS score above average (&gt; 68) before (69.6 ± 13.4) and after CR (68.6 ± 15.1). All HCPs (n = 8) found the application usable. Patient activation did not increase significantly after CR compared with baseline (62.0 ± 8.6 versus 59.2 ± 9.5, respectively, p = 0.28) and only physical activity levels improved significantly (2.4 ± 0.7 (standardised score) at baseline, 2.8 ± 0.4 after CR, p = 0.04).ConclusionThe LifeStyleScore application was found to be usable for patients receiving CR. Its use did not result in increased patient activation, and of the lifestyle behaviours only physical activity levels improved. Further research is needed to evaluate how such applications can be optimally incorporated in CR programmes

Predictors of cardiac rehabilitation referral, enrolment and completion after acute myocardial infarction: an exploratory study

BACKGROUND: Despite proven clinical benefits, only a minority of patients complete outpatient cardiac rehabilitation (CR) after acute myocardial infarction (AMI). The main purpose of this study was to evaluate to what extent and at which time patients drop out of CR, and to assess which patient-related characteristics can predict dropout. METHODS: In a retrospective cohort study, we selected patients who had been hospitalised with an AMI in our centre in 2015 or 2016. Patients were selected pseudonymously based on reimbursement codes in the electronic health record. We extracted baseline characteristics and data on CR referral, enrolment and completion for each patient. Multivariable logistic regression was used to assess which characteristics predicted referral and dropout. RESULTS: The 666 patients included were predominantly male (66%), with a mean age of 69.0 years. Of the 640 eligible patients, 201 (31%) were not referred for CR. Enrolment after referral was 94%. Nonreferral was independently associated with older age, female sex, traveling distance, non-ST-elevation myocardial infarction (NSTEMI; as compared with STEMI), no coronary revascularisation and prior manifestations of coronary artery disease. Of the 414 enrolled patients, 24% did not complete their CR programmes (i.e. dropped out). Older age and worse exercise capacity at baseline were independently associated with dropout. The ability of the multiple regression models to predict nonreferral and noncompletion was good to fair, with an area under the receiver operating characteristic curves of 0.86 and 0.71, respectively. CONCLUSION: The main reason for not participating in or not completing CR after AMI was nonreferral. To optimise CR utilisation, improvement of referral rates should be prioritised

Novel advances in cardiac rehabilitation:Position paper from the Working Group on Preventive Cardiology and Cardiac Rehabilitation of the Netherlands Society of Cardiology

Cardiac rehabilitation (CR) has evolved as an important part of the treatment of patients with cardiovascular disease. However, to date, its full potential is fairly underutilised. This review discusses new developments in CR aimed at improving participation rates and long-term effectiveness in the general cardiac population. It consecutively highlights new or challenging target groups, new delivery modes and new care pathways for CR programmes. These new or challenging target groups include patients with atrial fibrillation, obesity and cardiovascular disease, chronic coronary syndromes, (advanced) chronic heart failure with or without intracardiac devices, women and frail elderly patients. Also, the current evidence regarding cardiac telerehabilitation and loyalty programmes is discussed as new delivery modes for CR. Finally, this paper discusses novel care pathways with the integration of CR in residual risk management and transmural care pathways. These new developments can help to make optimal use of the benefits of CR. Therefore we should seize the opportunities to reshape current CR programmes, broaden their applicability and incorporate them into or combine them with other cardiovascular care programmes/pathways