A systematic review of economic evaluation of cardiac rehabilitation

Article (PDF Available)inBMC Health Services Research 12(1):243 · August 2012with72 Reads
DOI: 10.1186/1472-6963-12-243 · Source: PubMed
Abstract
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. 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. 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. 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

RES E AR C H A R T I C L E Open Access
A systematic review of economic evaluations of
cardiac rehabilitation
Wai Pong Wong
1,2*
, Jun Feng
3
, Keng Ho Pwee
4
and Jeremy Lim
5
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 Drummonds checklist.
Results: A total of 22 articles were selected for review. However five articles were further excluded because they
were cost-mi nimization 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.
Background
Cardiovascular diseases are a major cause of mortality
and morbidity, contributing to about 30% of all-cause
mortality and 10% of the total disability-adjusted life-
years globally [1]. Although advances in medical therapy
and revascularization surgery have improved outcome,
reducing risk factors associated with cardiovascular
diseases remains an important strategy in lowering the
global burden of disease [2]. Risk factor management is
a core component of cardiac rehabilitation, which in
turn forms part of the overall managemen t of patients
with cardiovascular diseases such as coronary artery dis-
ease or chronic heart failure [3,4].
Besides risk factor management (specifically control or
reduction of lipids, blood pressure, body weight, diabetes
mellitus and cigarette smoking), the other core compo-
nents of cardiac rehabilitation include nutritional and
physical activity counseling, psychosocial interventions
and exercise training [4]. In particular, exercise training is
often the component being examined under the umbrella
* Correspondence: WaiPong.Wong@SingaporeTech.edu.sg
Equal contributors
1
Academic Programmes Division, Singapore Institute of Technology, 25
North Bridge Road, Singapore, Singapore
2
Primary & Community Care Division, Ministry of Health, 16 College Road,
Singapore, Singapore
Full list of author information is available at the end of the article
© 2012 Wong et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Wong et al. BMC Health Services Research 2012, 12:243
http://www.biomedcentral.com/1472-6963/12/243
term cardiac rehabilitation, likely because of its duration
and therefore the cost of the program [5].
Several systematic reviews over the past three decades
have consistently demonstrated cardio-protective effects
of exercise-based cardiac rehabilitation programs [6-9].
Exercise-based cardiac rehabilitation, compared to usual
care, reduces all-cause mortality by 20% (95% confidence
interval, CI: 7%, 32%) and cardiac mortality 26% (95%
CI: 4%, 39%) [8]. Risk factors such as total chole sterol,
triglycerides, systolic blood pressure and self-reported
smoking habits were also significantly reduced [8]. The
pooled sample size for the most recent systematic review
was 8,940, most of whom had undergone at least two
months of cardiac rehabilitation under supervision of
professional exercise personnel [8]. This implies great
involvement of economic cost in the delivery of cardiac
rehabilitation.
Economic evaluation of cardiac rehabilitation has been
reported since the 1980s. A systematic review of eco-
nomic evaluation studies on cardiac rehabilitation, which
identified 15 studies, was reported in 2005. Based on
studies published between 1985 to 2004, supervised car-
diac rehabilitation, compared to usual care, resulted in
USD2,193 to USD28,193 per life year gained, and USD668
to USD16,118 per quality-adjusted life years(monetary
values were 2004 US dollars) [10]. Most of the studies
reviewed up to 2004 were based on prospective rando-
mized controlled trials conducted much earlier than their
published dates. Over the past five years, more economic
evaluation studies emerged. These studies might involve
patients who have undergone more recent medical therap-
ies for coronary artery disease and chronic heart failure.
Recent studies have also focused on comparisons among
different modes of delivery of cardiac rehabilitation, such
as programs that were outpatient-, inpatient- as well as
home-based. Therefore it is timely to systematically re-
view and summarize the evidence on cost-effectiveness of
cardiac rehabilitation.
The overall objective of the current systematic review
was to describe and summarize published economic eva-
luations of cardiac rehabilitation for comparing the cost-
effectiveness of different modes of delivery of cardiac
rehabilitation. The specific aims were to compare the
following modes of delivery:
(a) supervised cardiac rehabilitation versus no cardiac
rehabilitation,
(b) supervised versus home-based cardiac
rehabilitation,
(c) inpatient (not Phase I ward program, but
residential Phase II program) versus outpatient
cardiac rehabilitation, and
(d) home-based cardiac rehabilitation versus no
cardiac rehabilitation.
In this review, cardiac rehabilitation is considered as
consisting of at least exercise training sessions, as this is
usually the component studied as well as being the main
cost driver of cardiac rehabilitation programs.
Methods
Search strategy
Prior to developing the search strategy, PICO state-
ments were used to address the specific aims of the sys-
tematic review (Table 1). The electronic databases of
EMBASE, MEDLINE, NHS EED, PEDro and CINAHL
was searched using the text word terms of economic
evaluation, cost, cost-effectiveness, cost-benefit or cost-
utility,andcardiac rehabilitation up to May 2010. Hand
searches of bibliographies of each reference followed to
identify any additional publications. Unpublished or grey
literature was not included.
Selection criteria
For the purpose of this review, the inclusion criteria
were as follows:
Economic evaluation study design that was either
prospective alongside a clinical trial or based on
modeling;
Adult patients diagnosed with acute myocardial
infarction (including post-infarction and after
revascularization surgery or percutaneous coronary
intervention for infarct), or chronic heart failure;
Table 1 PICO statements used to develop the search to address the four different modes of delivery
PICO (a) (b) (c ) (d)
Population Patients diagnosed
with acute MI
or chronic HF
Patients diagnosed
with acute MI or
chronic HF
Patients diagnosed
with acute MI or
chronic HF
Patients diagnosed
with acute MI or
chronic HF
Intervention Supervised
outpatient CR
Supervised
outpatient CR
Supervised
outpatient CR
Home-based CR
Comparison Usual/standard care
(i.e., no CR)
Home-based CR Supervised
inpatient CR
Usual/standard care
(i.e., no CR)
Outcome Cost-effectiveness Cost-effectiveness Cost-effectiveness Cost-effectiveness
MI, myocardial infarction; HF, heart failure; CR, cardiac rehabilitation.
Wong et al. BMC Health Services Research 2012, 12:243 Page 2 of 8
http://www.biomedcentral.com/1472-6963/12/243
Intervention that included exercise-based cardiac
rehabilitation;
Study with at least one of four comparators listed in
Table 1;
Outcomes included either cost-effectiveness , cost-
utility or cost-benefit analysis. Cost-minimization
analysis was not included.
Articles were excluded if one of the elements of PICO
(Table 1) was not met.
Quality assessment
The 10-item Drummond checklist was used to assess
the methodological quality of the economic evaluation
studies [11]. If the study met any of these 10 items, it
would be considered as Yes, otherwise No or Cannot
tell (Additional file 1: Appendix 1). The Drummond
checklist provides a global assessment of the quality of
evidence, but does not form the basis for accepting or
rejecting articles.
Data abstraction
Two independent reviewers (JF and WPW) selected
eligible publications initially based on titles and abstracts.
Potentially relevant articles were abstracted using stan-
dardized data abstraction form. This form was also used
for data synthesis. Any disagreement between the
reviewers was resolved by consultation with a third re-
viewer (KHP).
Results
Synthesis
A total of 896 citations were retrieved based on the
search strategy. Of the 62 articles retrieved for more
detailed evaluation, only 20 were included. An additional
two references from hand searches yielded a total of 22
[12-33] articles for review. Five articles were con-
cerned with cost-minimization analyses, whilst one
article included data from patients with stroke in its eco-
nomic modelling. The remaining 16 articles included one
article that addr essed both centre-based cardiac rehabili-
tation versus no rehabilitation, and home-based cardiac
rehabilitation versus no rehabilitation. Among the six
foreign-language articles, three did not meet the inclu-
sion criteria, two were editorials or commentaries and
one was deemed irrelevant after reading through the full
article. Therefore, only 16 articles were included. Figure 1
describes the reasons for not including the articles.
The majority of the articles clearly stated that they
included patients after acute myocardial infarction, follow-
ing revascularization surgery or percutaneous coronary
interventions, or who had a diagnosis of chronic heart
failure, and therefore satisfied the selection criterion on
diagnosis. Two articles employed the same sample for
analyses , involving patients with coronary artery disease,
defined as acute myocardial infarction or angina pectoris
[25,27]. One study included patients with coronary artery
disease, defined as acute myocardial infarction (75% and
79% respectively in both groups) or post-angioplasty
(25% and 21% respectively) [32]. In another study,
Potentially relevant studies
identified and screened for
retrieval (n=897)
Studies excluded
Reason:
The articles were very likely to be irrelevant
based on titles and abstracts (n=835)
Studies retrieved for more
detailed evaluation (n=62)
Studies included in the final
review (n=16)
Further studies excluded,
Reasons (n=48)
1. Not meeting inclusion criteria (n=33)
2. Reviews/editorials/commentaries (n=13)
3. Irrelevant after reading the whole paper (n=1)
4.
Articles using the same datasets and having
the same conclusions
(n=1)
Studies from
hand searches of
bibliographies of
references (n=2)
Figure 1 Flow of included studies.
Wong et al. BMC Health Services Research 2012, 12:243 Page 3 of 8
http://www.biomedcentral.com/1472-6963/12/243
patients after acute myocardial infarction accounted for
39%, chronic heart failure 22%, angina 45%, arrhythimias
59%, and valvular disease 26% [30].
The quality of these articles varied. Articles fulfilled two
to nine items on the Drummond checklist, with none of
them meeting all the items (Additional file 1: Appendix 1).
Table 2 summarizes the economic evaluations reported
in these studies (details in Additional file 2: Appendix 2).
Five of these studies were cost-minimization analysis,
and therefore were strictly not considered as full eco-
nomic evaluations [11].
Supervised (or centre-based) cardiac rehabilitation versus
no cardiac rehabilitation (usual/standard care)
A total of nine studies examined the cost-effectiveness of
supervised centre-based cardiac rehabilitation compared
to no cardiac rehabilitation. Most of the economic stud-
ies were conducted prospectively alongside randomized
controlled trials (RCT) [14,16-18], whilst three studies used
modeling to derive long-term cost-effectiveness [14-16].
All the studies suggested that cardiac rehabilitation super-
vised at a facility compared to no cardiac rehabilitation
was cost-saving [12,13,20], cost-effective [14,17,19] and a
dominant strategy (that is, less cost, more effective)
[16,18]. However, cost-effectiveness could become less
because of escalating medical costs, as demonstrated by
one modeling study [15].
Supervised (or centre-based) versus home-based cardiac
rehabilitation
Among 10 studies, six yielded no significant differ-
ences in the clinical outcome measures, and wer e there-
fore technically considered cost-minimization analyses
[17,21,23,24,28,33]. Of the remaining four studies, one
study employed economic modelling in cost-effectiveness
analysis, using data from patients with cardiovascular
disease, defined as self-report of previous heart attack,
stroke, or other heart disease [22]. Among the three
included studies (Table 3), one showed that centre-
based strategy was dominant compared to home-based
rehabilitation [27], whilst two studies demonstrated no
difference in cost-effectiveness [25,26]. In one of the
cost-minimization analyses, cost to the government
(taxation-based health care syste m) was greate r with
home-based program than centre-based program, likely
due to frequent home visits by hospital staff [28]. The
definition of home-based program varied amon g the
three studies, involving combinations of home visits
[25,26] and decreased frequency of centre-based rehabili-
tation attendances [25,27].
Inpatient versus outpatient cardiac rehabilitation
The only study that evaluated cost-effectiveness between
inpatient and outpatient cardiac rehabilitation demon-
strated no significant difference [29] (Table 4).
Table 2 Summary of economic evaluations comparing supervised centre-based cardiac rehabilitation (CR) vs no cardiac
rehabilitation (No-CR)
Author (Year) Perspective Patient populations Study type Currency, price year Findings
Levin et al. (1991) Societal N = 305 after MI CCA Swedish kroner, ?year CR: SEK73,500 less per patient
Ades et al. 1992 Patients/ payers N = 580 after MI/CABG CCA US dollars, 1991 CR: $739 less in hospitalization
costs per patient
Oldridge et al. (1993) Societal N = 201 after MI CUA/ modelling US dollars, 1991 CR: $21,800 per life-year
gained; $9,200 per QALY
gained at 1 year
Ades et al. (1997) Patients/ Payers Not applicable Economic modeling US dollars, 1995 CR: $4,950 per year
of life saved
Georgiou et al. (2001) Societal N = 99 with HF CEA US dollars, 1999 ICER = $1,773 per life year
saved in favour of CR
Marchionni et al. (2003) Government
or care providers
N = 158 with MI CCA US dollars, 2000 CR: $21,298 per patient vs
$12,433 per patient in
No-CR group
Yu et al. (2004) Government N = 204 after MI or PCI CUA US dollars, ?year ICUR = $650 per QALY
in favour of CR
Huang et al. (2008) Government N = 4,324 after CABG CEA US dollars, 1998 ICER = 13,887 per year
of life saved
in favour of CR
Dendale et al. (2008) Health care payers N = 213 after PCI CEA Euro, ?year CR: 4,862 per patient
and 5,498 per patient
in No-CR group
MI, myocardial infarction. HF, heart failure. CABG, coronary artery bypass graft surgery. PCI, percutaneous coronary intervention. CCA, cost-consequences analysis.
CEA, cost-effectiveness analysis. CUA, cost-utility analysis. QALY, quality-adjusted life-years. ICER, incremental cost-effectiveness ratio. ICUR, incremental cost-utility
ratio.
Wong et al. BMC Health Services Research 2012, 12:243 Page 4 of 8
http://www.biomedcentral.com/1472-6963/12/243
Home-based cardiac rehabilitation versus no cardiac
rehabilitation (usual/standard care)
Four studies considered the cost-effectiveness of home-
based program compared to no cardiac rehabilitation
program. Home-based program was considered afford-
able [32] and more cost-effective than no cardiac re-
habilitation [17]. Two studies demonstrated cost-savings
[30,31] with home-based program. Of interest was the
internet-based program by one of these studies [31].
Discussion
This systematic review summarizes the cost-effectiveness
of cardiac rehabilitation compared to no cardiac rehabili-
tation, for patients after myocardial infarction, revasculari-
zation surgery or percutaneous coronary interventions,
as well as those with chronic heart failure. Pooling of
results is not possible given the heterogeneity in per-
spectives, health systems, study designs, details of cardiac
rehabilitation interventions and types of patients that
exist among the studies included in this review. However,
we contend that these studies provide sufficient evidence
for policy development concerning cardiac rehabilitation.
Inclusion of a supervised outpatient cardiac rehabilita-
tion program is clearly more cost-effective than not in-
cluding cardiac rehabilitation program (usual or standard
care) into the overall management of patients after myo-
cardial infarction or those with chronic heart failure. The
centre-based programs consisted of exercise-based ses-
sions, three times a week, over a period of 8 to 12 weeks.
In addition, risk factor management and other multi-
disciplinary input were included in half of these studies.
Four of the nine studies were economic e valuations
alongside prospective randomized controlled trials [14,16-
18]. Two of these studies examined cost-effectiveness
from the societal perspective within differing health
systems [14,16]. In the Canadian health system, cardiac
rehabilitation compared to usual care had an incremental
cost-effectiveness of USD9,200 per quality-adjusted life-
year (QALY) gained as well as USD21,800 per life-year
saved (1991 US dollars) at 12 months [14]. In the United
States private health care system, cardiac rehabilitation
was the dominant strategy compared to no cardiac re-
habilitation with $1,773 (2001 US dollars) per life-year
saved at 14 months [16]. Recent economic studies with
non-randomized group allocation designs corroborated
this observation, for example, an incremental cost-
effectiveness ratio of $13,887 per life-year saved (1998 US
dollars) was estimated based on Medicare expenditures
for American patients undergoing cardiac rehabilitation;
these patients had concomitant end-stage renal failure re-
quiring haemodialysis and post-coronary artery bypass
graft surgery [19]. In Belgian patients following percutan-
eous coronary interventions, cardiac rehabilitation led to
reduced hospitalization and revascularization surgery, and
subsequently cost (published in 2008, in euros) [20]. One
economic modeling study suggested that cost savings could
become less over the years as a result of rising health care
costs [15]. Much of the cost escalation could be attributed
to the high costs of cardiac investigations and surgery, in
addition to the personnel-intense multidisciplinary cardiac
rehabilitation program [26]. Therefore, home-based pro-
grams have been touted as a cost-effective alternative.
Comparisons between home-based and centre-based
programs were predominantly cost-minimization studies
[17,21,23,24,28,33]. In all these studies, the consequences
of both alternatives were equivalent, so the authors sought
to only compare their costs. Despite different settings,
these studies consistently showed that home- and centre-
based cardiac rehabilitation to be similar in cost.
Although all 13 studies (including cost-minimization
analyses) on home-based cardiac rehabilitation, compared
to either supervised centre-based programs or no cardiac
Table 3 Summary of economic evaluations comparing supervised centre-based cardiac rehabilitation (CR) vs
home-based cardiac rehabilitation (HCR)*
Author (Year) Perspective Patient populations Study type Currency, price year Findings
Reid et al. (2005) Health system N = 392 CAD CCA US dollars, 2004 HCR: $5,267 per patient
CR: $5,132 per patient; no difference
Taylor et al. (2007) Societal N = 80 MI CUA Sterling pounds, 2002-3 ICUR = £644 per QALY in favour
of CR but not significantly different
Papadakis et al. (2008) Health system N = 392 CAD CUA US dollars, 2004 ICUR = $11,400 per QALY in favour of CR
MI, myocardial infarction. CAD, coronary artery disease. CCA, cost-consequences analysis. CUA, cost-utility analysis. QALY, quality-adjusted life-years. ICUR,
incremental cost-utility ratio. * cost-minimization analyses were not included in this table (refer to Additional file 2: Appendix 2 for details).
Table 4 Summary of economic evaluations comparing supervised centre-based inpatient cardiac rehabilitation (ICR) vs
supervised centre-based outpatient cardiac rehabilitation (CR)
Author (Year) Perspective Patient populations Study type Currency, price year Findings
Schweikert et al. (2009) Societal N = 147 MI CEA/CUA Euro, 2006 ICER = 165,276 per QALY in favour of CR,
although no significant
MI, myocardial infarction. CEA, cost-effectiveness analysis. CUA, cost-utility analysis. QALY, quality-adjusted life-years. ICER, incremental cost-effectiveness ratio.
Wong et al. BMC Health Services Research 2012, 12:243 Page 5 of 8
http://www.biomedcentral.com/1472-6963/12/243
rehabilitation, have demonstrated home-based model to
be cost-effective or cost-saving, the contents of the home-
based programs varied widely. The contents of home-
based program ranged from actual exercise sessions at
home [21,22,33], frequent home visits by case managers
and physicians [24-26,28], to reduced or more spaced-out
attendances at the centre [17,23,25,27]. Exercise participa-
tion has to be regular to be effective. The option of
reduced or spaced-out attendances at the centre is primar-
ily to encourage the patients to continue with the exercises
at home, whilst providing opportunity to return to the
centre for reinforcement, monitoring and evaluation.
One program was internet-based, requiring computer lit-
eracy, internet access at home and frequent log-ons to
the web site to update on completion of exercises [31].
Early studies (before 2005) tended to demonstrate that
home-based programs were more cost-effective and cost-
saving than centre-based ones [ 17,21-24,33]. Sensitivity
analyses in some of these studies have shown no change
to the conclusion despite taking the worst-case scenario
[17] or varying variables such as costs [24], readmission
rates [24], patients travelling time [24], exercise adherence
[22] and discounting rates [22,24]. Home-based pro-
grams in these studies were varied, including program
with reduced sessions at the centre to exercise program
conducted entirely at home with or without frequent
home visits by health care professionals (see Table 3).
However, the recent studies have shown otherwise
[25-28]. Three recent studies demonstrated no significant
difference in the cost-effectiveness of centre- versus
home-based programs [25,26,28]. In one study, sensitivity
analyses by taking the upper estimate of UK hospital
rehabilitation costs did not alter the conclusion, be cause
cardiac-related costs far exceeded rehabilitation costs
[26]. All three economic evaluations were conducted
alongside randomized controlled trials, within a taxation-
based health care system (Canada and UK) and involved
multiple home visits by health care professionals (case
managers, physicians and rehab nurses). One recent study
demonstrated greater quality adjusted life-year gained
among participants in centre-based program than those
in home-based program [27]. The home-based program
in this study was 33 cardiac rehabilitation sessions spread
across 12 months, whereas the centre-based program was
the same 33 sessions conducted over 3 months. Interest-
ingly, these authors found that the spread-out program
was more cost-effective among women whilst the centre-
based program was more cost-effective among men [27].
Thus, the cost-effectiveness of the so-called home-based
cardiac rehabilitation program depends heavily upon its
contents as well as patient profiles. Policy decision makers,
and payers or purchasers of cardiac rehabilitation services,
should take into consideration of the model of home-
based programs when considering resource allocation.
The use of information and communication technology
and internet-based programs should be explored, and
therefore further studies could compare internet- versus
centre-based programs in terms of cost-effectiveness.
Limitations
None of the 16 articles met all of Drummonds 10-item
checklist (Table 2). Articles were dated as early as 1985
and as recently as 2009, with 13 of the articles published
in the la st 10 years. Majority of the studies collected and
analyzed only direct medical costs. Few studies considered
sensitivity analysis to account for uncertainty in costs
and consequences. Although none of the foreign-language
articles were included, none met the inclusion criteria for
review. Publication bias cannot be excluded as almost all
the economic evaluations demonstrated cost-effectiveness.
Conclusions
In conclusion, evidence exists that supports the inclusion
of supervised outpatient centre-based or home-based
cardiac rehabilitation compared to no cardiac rehabilita-
tion in patients after myocardial infarction, revasculariza-
tion surgery or percutaneous coronary interventions, as
well as those with chronic heart failure. Based on the
reviewed articles, it would appear that the costs and out-
comes of home- versus supervised centre-based cardiac
Table 5 Summary of economic evaluations comparing home-based cardiac rehabilitation (HCR) and no cardiac
rehabilitation (No-CR)
Author (Year) Perspective Patient populations Study type Currency, price year Findings
Wheeler et al. (2003) Patients/ payers N = 452 women with MI, HF, etc. CCA US dollars, 2000 HCR: 49% lower inpatient cost;
46% fewer inpatient days
Southard et al. (2003) Patients N = 104 MI, CABG, HF CCA/ CBA US dollars, ?year HCR: cost $1,418 less with
213% return on investment
Marchionni et al. (2003) Government
or care providers
N = 153 MI CCA US dollars, 2000 HCR: $13,246 per patient;
better outcomes
No-CR: $12,433 per patient
Salvetti et al. (2008) Health providers N = 39 CAD CCA US dollars, ?year HCR: $502.71 more per patient
MI, myocardial infarction. HF, heart failure. CABG, coronary artery bypass graft surgery. CAD, coronary artery disease. CCA, cost-consequences analysis. CUA,
cost-utility analysis. CBA, cost-benefit analysis.
Wong et al. BMC Health Services Research 2012, 12:243 Page 6 of 8
http://www.biomedcentral.com/1472-6963/12/243
rehabilitation were no different. Therefore the choice of
the mode of delivery (home- versus centre-based) should
be left to purchasers and patients. To the policy decision
makers, there could be possible economic advantage of
home-based program over centre-based ones. However,
the details of what constitute home-based program are
important.
Additional files
Additional file 1: Appendix 1. Quality assessment with the 10-item
Drummond checklist [11].
Additional file 2: Appendix 1. Summary of Studies on Economic
Evaluations of Cardiac Rehabilitation (CR).
Competing interests
The authors declare that they have no competing interests.
Authors contributions
WPW and JF performed article search and screened the abstracts. KHP
resolved any disagreements arising from the primary reviewers
interpretations of the articles and provided input to the manuscript. JL
provided input to the interpretation of the review and discussion. All authors
read and approved the final manuscript.
Acknowledgements
We thanked Brian Choi for input to the initial phase of the systematic review.
At the time of this work, JF and KHP were with the Health Services Research
and Evaluation Division and JL was with the Primary and Community Care
Division, Ministry of Health.
Author details
1
Academic Programmes Division, Singapore Institute of Technology, 25
North Bridge Road, Singapore, Singapore.
2
Primary & Community Care
Division, Ministry of Health, 16 College Road, Singapore, Singapore.
3
OptumInsight, 370-372 Norton Street, New South Wales, Australia.
4
Performance and Technology Assessment Division, Ministry of Health,
College Road, Singapore, Singapore.
5
Fortis Healthcare Singapore, 180
Clemenceau Avenue, Singapore, Singapore.
Received: 27 July 2011 Accepted: 24 July 2012
Published: 8 August 2012
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):27462753.
2. Levenson JW, Skerrett PJ, Gaziano JM: Reducing the global burden of
cardiovascular disease: the role of risk factors. Prev Cardiol 2002,
5(4):188199.
3. Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA, Certo
CME, Dattilo AM, Davis D, DeBusk RF, et al: Cardiac Rehabilitation. Clinical
Practice Guideline No. 17. Rockville, MD: 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; 1995.
4. 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):26752682.
5. 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):905911.
6. O'Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger
RS Jr, Hennekens CH: An overview of randomized trials of rehabilitation
with exercise after myocardial infarction. Circulation 1989, 80(2):234244.
7. Oldridge NB, Guyatt GH, Fischer ME, Rimm AA: Cardiac rehabilitation after
myocardial infarction. Combined experience of randomized clinical trials.
JAMA 1988, 260(7):945950.
8. 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):682692.
9. 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.
10. 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):513520.
11. Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL: Methods
for the economic evaluation of health care programmes. 3rd edition. New
York: Oxford University Press; 2005.
12. Levin LA, Perk J, Hedback B:
Cardiac rehabilitationa cost analysis. J Intern
Med 1991, 230(5):427434.
13. Ades PA, Huang D, Weaver SO: Cardiac rehabilitation participation
predicts lower rehospitalization costs. Am Heart J 1992,
123(4 Pt 1):916921.
14. 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):154161.
15. Ades PA, Pashkow FJ, Nestor JR: Cost-effectiveness of cardiac
rehabilitation after myocardial infarction. J Cardiopulm Rehabil 1997,
17(4):222231.
16. 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):984988. A984.
17. 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):22012206.
18. 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):19151922.
19. 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):10791084.
20. 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):451456.
21. DeBusk RF, Haskell WL, Miller NH, Berra K, Taylor CB, Berger WE 3rd, 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):251257.
22. 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.
23. 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):1723.
24. Collins L, Scuffham P, Gargett S: Cost-analysis of gym-based versus
home-based cardiac rehabilitation programs. Aust Health Rev 2001,
24(1):5161.
25. 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):862868.
26. 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):196201.
Wong et al. BMC Health Services Research 2012, 12:243 Page 7 of 8
http://www.biomedcentral.com/1472-6963/12/243
27. 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):347353.
28. 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):3642.
29. 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):787795.
30. 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):706715.
31. 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):341348.
32. 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(1011):987996.
33. 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):1018.
doi:10.1186/1472-6963-12-243
Cite this article as: Wong et al.: A systematic review of economic
evaluations of cardiac rehabilitation. BMC Health Services Research 2012
12:243.
Submit your next manuscript to BioMed Central
and take full advantage of:
Convenient online submission
Thorough peer review
No space constraints or color figure charges
Immediate publication on acceptance
Inclusion in PubMed, CAS, Scopus and Google Scholar
Research which is freely available for redistribution
Submit your manuscript at
www.biomedcentral.com/submit
Wong et al. BMC Health Services Research 2012, 12:243 Page 8 of 8
http://www.biomedcentral.com/1472-6963/12/243
    • "CR participation is related to significantly reduced mortality and morbidity [17], and therefore is recommended in cardiovascular practice guidelines around the world363738. Given these benefits and its' cost-effectiveness [15], it is disconcerting how little CR is available to those with CVD [22]. We identified only 8 CR programs in the Arab world, and many of these were newly opened. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Despite the high burden of cardiovascular diseases in Arab countries, little is known about cardiac rehabilitation (CR) delivery. This study assessed availability, and CR program characteristics in the Arab World, compared to Canada. Methods: A questionnaire incorporating items from 4 national / regional published CR program surveys was created for this cross-sectional study. The survey was emailed to all Arab CR program contacts that were identified through published studies, conference abstracts, a snowball sampling strategy, and other key informants from the 22 Arab countries. An online survey link was also emailed to all contacts in the Canadian Association of Cardiovascular Prevention and Rehabilitation directory. Descriptive statistics were used to describe all closed-ended items in the survey. All open-ended responses were coded using an interpretive-descriptive approach. Results: Eight programs were identified in Arab countries, of which 5 (62.5 %) participated; 128 programs were identified in Canada, of which 39 (30.5 %) participated. There was consistency in core components delivered in Arab countries and Canada; however, Arab programs more often delivered women-only classes. Lack of human resources was perceived as the greatest barrier to CR provision in all settings, with space also a barrier in Arab settings, and financial resources in Canada. The median number of patients served per program was 300 for Canada vs. 200 for Arab countries. Conclusion: Availability of CR programs in Arab countries is incredibly limited, despite the fact that most responses stemmed from high-income countries. Where available, CR programs in Arab countries appear to be delivered in a manner consistent with Canada.
    Full-text · Article · Nov 2015
    • "Exercise training based cardiac rehabilitation Wong et al (2012) 75 16 "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Health related rehabilitation is instrumental in improving functioning and promoting participation by people with disabilities. To make clinical and policy decisions about health-related rehabilitation, resource allocation and cost issues need to be considered. Objectives: To provide an overview of systematic reviews (SRs) on economic evaluations of health-related rehabilitation. Methods: We searched multiple databases to identify relevant SRs of economic evaluations of health-related rehabilitation. Review quality was assessed by AMSTAR checklist. Results: We included 64 SRs, most of which included economic evaluations alongside randomized controlled trials (RCTs). The review quality was low to moderate (AMSTAR score 5-8) in 35, and high (score 9-11) in 29 of the included SRs. The included SRs addressed various health conditions, including spinal or other pain conditions (n = 14), age-related problems (11), stroke (7), musculoskeletal disorders (6), heart diseases (4), pulmonary (3), mental health problems (3), and injury (3). Physiotherapy was the most commonly evaluated rehabilitation intervention in the included SRs (n = 24). Other commonly evaluated interventions included multidisciplinary programmes (14); behavioral, educational or psychological interventions (11); home-based interventions (11); complementary therapy (6); self-management (6); and occupational therapy (4). Conclusions: Although the available evidence is often described as limited, inconsistent or inconclusive, some rehabilitation interventions were cost-effective or showed cost-saving in a variety of disability conditions. Available evidence comes predominantly from high income countries, therefore economic evaluations of health-related rehabilitation are urgently required in less resourced settings.
    Full-text · Article · Oct 2015
    • "Patients who adhere to CPMR programs experience improved quality of life, hemodynamic stabilization, metabolic changes, and improved vascular and psychological states, which are associated with better control of risk factors and improvement in lifestyle1516. Studies have already demonstrated the cost-effectiveness of CPMR, which became necessary for the rehabilitation of patients affected by these diseases89 12]. However, there are several uncertainties surrounding the professionals who work in CPMR. "
    [Show abstract] [Hide abstract] ABSTRACT: An influence diagram (ID) is a method of graphical representation of uncertain knowledge, which can be employed to support decisions in health care using probabilistic reasoning. We aimed to describe the development of an ID to support the decision-making process in phase II at Cardiopulmonary and Metabolic Rehabilitation Program (CPMR). The development of the ID was carried out through the identification of relevant variables and their possible values, as well as the identification of details of each variable, in order to find a network structure that appropriately connects the nodes that represent the variables, with arcs linking acyclic graphs, and to build the graph using specialized knowledge and the conditional probability table for each node in the graph. In spite of the complexity of the interactions, the model obtained with the ID seems to contribute in the decision-making process in phase II CPMR, providing a second opinion to the health pratictioner and helping in diagnostic, therapeutic and decision-making processes, since it is useful in situations with non-linear modeling or with absent or uncertain information.
    Full-text · Conference Paper · Aug 2015
Show more

Supplementary resources