ARTICLE SUMMARY

The economic impact of cardiovascular disease, including the impacts of coronary heart disease (CHD), on the U.S. economy is an estimated $407 billion, including $251 billion in medical costs and $156 billion in lost productivity. While we know that cardiac rehabilitation (CR) can significantly reduce mortality in patients with CHD, the author group of the new JCRP Article “Cost-Effectiveness of Cardiac Rehabilitation in Older Adults with Coronary Heart Disease” set out to quantify the incremental cost-effectiveness ratio (ICER) of CR using the framework from the Second Panel on Cost-Effectiveness Analysis and the World Health Organization Macro-Economic Commission on Health.

The population and cost data used for this analysis came from Medicare records – specifically a population of 601,099 Medicare beneficiaries aged 65 and above that were hospitalized in 1997 for CHD. This large-scale study, which followed patients until death or for a maximum of 5 years, is to date the largest evaluation of CR in older adults. Of this population, 12% (or 73,049 beneficiaries) attended at least one session of CR, and 88% did not attend CR. To assess the cost-effectiveness of participation in CR, the author group used national life tables to model lifetime costs (adjusted to 2022 prices) and quality-adjusted life years (QALY) gained.*

These investigators found that costs were similar between the CR participants and non-participants during the initial hospitalization, but in the first year following discharge, costs were higher for the CR patients, primarily due to participation in CR. However, in years 2-5, CR participants showed a lower cost of institutional care than non-participants. An increase in ambulatory care was noted over the same 2-5 year period for CR patients, but the author group proposes that this is likely due to CR participants understanding the importance of routine healthcare visits and preventative care on their long-term health and quality of life.

Focusing on QALY gained, the investigators found that depending on the method used to calculate QALY, CR added between 1.344 QALY (a 17% gain over the course of the patient’s lifetime) and 2.018 QALY (a 19.1% gain over the course of the patient’s life).

To help healthcare providers and policymakers determine the effectiveness of medical interventions, the World Health Organization Macro-Economic Commission on Health recommends an ICER of $75,180/QALY saved for United States-based patients.** Based on the results of the current analysis, CR had an ICER of between $30,188 and $32,996/QALY saved. Regardless of the method used, these analyses demonstrate that CR is a highly cost-effective intervention for patients with CHD.

The results of this paper further solidify the cost-effectiveness of CR in older patients with CHD, and they make a strong case for increased utilization of CR in this population. In the article, the author group advocates for the use of the Million Hearts® Cardiac Rehabilitation Change Package to help drive an increase in the utilization of CR and also suggests a more broad financial strategy of increasing healthcare payments and decreasing direct patient costs like copays to ensure more CHD patients experience the benefits of CR. 

The full article, “Cost-Effectiveness of Cardiac Rehabilitation in Older Adults With Coronary Heart Disease,” can be viewed by accessing JCRP through the AACVPR Member portal on the AACVPR website.

*Quality-adjusted life years (QALY) is a metric used frequently in economic analyses to determine the value of healthcare interventions by quantifying the impact of the intervention on a patient’s length and quality of life. Essentially, this metric is looking at the amount of additional time of a reasonable quality that is added to a patient’s life after a specific healthcare intervention is performed. A result of 0 would indicate death, and a 1 would indicate a perfect year of health.

**The World Health Organization Economic Commission on Health recommends that medical interventions aim to cost less than the per-capita gross domestic product of the country for each QALY added. The United States per-capita gross domestic product as of 2022 is $75,180, so interventions would need to cost less than that figure per QALY gained for the patient to be considered cost effective.

Article Authors: Donald S. Shepard, PhD; Shehreen Zakir, MS, BDS; Diann E. Gaalema, PhD; Philip A. Ades, MD