Cardiac rehabilitation: how much pain for the optimal gain?
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Cardiac rehabilitation: how much pain for the optimal gain? J. A. Snoek & M. J. M. Cramer & F. J. G. Backx
Published online: 14 February 2013 # Springer Media / Bohn Stafleu van Loghum 2013
Exercise-based cardiac rehabilitation (CR) is effective in reducing total and cardiovascular mortality and hospital admissions with a reported relative risk of 0.87 (95 % CI 0.75, 0.99), 0.74 (95 % CI 0.63, 0.87) and 0.69 (95 % CI 0.51, 0.93) respectively [1]. This is a similar relative risk reduction as quitting smoking [2]. For all patients with an acute coronary syndrome (ACS), and for those who have undergone coronary artery bypass grafting (CABG), valvular surgery or even percutaneous coronary interventions (PCI) CR is widely recommended [3, 4]. Supervised CR (hospital or CR centre) is cost-effective for patients with myocardial infarction (MI) and heart failure compared with usual care (e.g. drug therapy) [5]. The present literature evaluating home-based and alternative delivery models of cardiac rehabilitation is insufficient to draw definite conclusions about cost-effectiveness. One of the few studies that evaluated the cost-effectiveness of supervised exercise-based CR by combining cost information with time trade-off measures of health-related quality of life and data on mortality, concluded that CR was an efficient use of health-care resources and may be economically justified [6]. In 2004, Yu et al. demonstrated, with a cost-utility analysis, a savings of $668 per QALY gained at the end of 2 years of CR in a sample of MI and PTCA patients in Hong
J. A. Snoek (*) Sport Medicine Department, Isala Clinics Zwolle, PO Box 10500, 8000 GM, Zwolle, the Netherlands e-mail: [email protected] M. J. M. Cramer Cardiology Department, University Medical Centre Utrecht, Utrecht, Netherlands F. J. G. Backx Sport Medicine Department, University Medical Centre Utrecht, Utrecht, Netherlands
Kong [7]. Both studies show that the cost/QALY are well under the accepted range of $20,000/QALY. This is considered highly cost-effective. Nevertheless despite the evidence for the reduction in morbidity and mortality and the cost effectiveness of CR, less than a third of the patients eligible for CR actually receive CR in the Netherlands [8]. Van Engen-Verheul et al. demonstrated that among patients who were diagnosed with an acute coronary syndrome (ACS) and/or therapeutic interventions (CABG, valve surgery or PCI, only 28.5 % received CR within the following year [8]. Among patients with chronic cardiovascular disease, CR participation was even lower. Determinants associated with lower CR uptake were: female gender, older age, type of intervention (i.e. higher CR uptake after CABG and lower CR uptake after elective PCI as compared with acute PCI), diagnosis (i.e. lower CR uptake in patients with unstable AP as compared with myocardial infarction), comorbidity, and a larger distance to the nearest CR provider. In 2011 the Netherlands Society of Cardiology and the Dutch Heart Association updated their guideline for CR [2]. CR
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