Cardiac rehabilitation programmes: Cost-effective and a potential instrument against health inequalities

Cardiac rehabilitation (CR) programmes have gained increasing recognition in past decades, and their benefits are well established in a wide range of scenarios, from heart failure to post myocardial infarction (MI) or cardiac surgery. In time, CR programmes have progressed from having a physical activity focus to a more wide-ranging type of horizon, where components such as patient education, psychological support, behaviour modification and general wellbeing have also been incorporated into the package.1 Overall, the benefits attributed to CR go as high as increasing survival by 25% across the literature.2 It is worth noting that its appeal is not only limited to improving exercise levels, which have been proved to reduce mortality in patients with ischaemic heart disease,3 but also as a powerful tool to improve psychological health as well as to control other cardiovascular risk factors.4 Moreover, previous health economic systematic reviews have proved these programmes also to be cost-effective,5 although a common net benefit is challenging to report due to the heterogeneous types of CR programmes and the different cost–utility measures used across the studies. Even with the limitations faced when trying to assess their true economic value, the potential health benefits gained from CR programmes at the current prices are difficult to match in the cardiovascular setting, particularly if we consider the remarkable costs of novel therapies arriving on the market. Therefore, international guidelines are unanimous in the recommendation that patients should be enrolled in a CR programme after MI.4 However, the uptake of CR therapy is one of its major setbacks, with almost half of patients missing out on the potential benefits worldwide. CR uptake varies from 30% in Canada and the USA, 50–70% in the UK and approximately 50% in the rest of Europe.6 These figures would be unacceptable if we were talking about medical treatment (such as antiplatelet or beta-blocker therapies) in a secondary prevention setting. When so much has been written about the overuse of medical treatments around the world, the price of underusing a therapy with a reported 25% survival benefit deserves more attention. This is especially relevant for patients from deprived socioeconomic settings, who already have a twofold relative risk of coronary artery disease mortality,7 and face greater obstacles to access and complete CR packages. In this edition of the journal Hinde et al.8 explore the cost-effectiveness of CR using the most updated meta-analysis data published by Anderson et al.9 in 2016. In their Cochrane review, Anderson et al. included more than 60 randomised controlled trials published since 2011 that used exercise-based CR programmes as the intervention in patients who had an MI, coronary revascularisation (percutaneous coronary intervention or bypass surgery), angina pectoris or patients with coronary artery disease. The comparison was the ‘usual care’, which did not include exercise or further lifestyle advice. The CR programmes included in the review varied from exercise-based only to more comprehensive types of models, which also included psychological support and behaviour change targets. Overall, the meta-analysis found a reduction in cardiovascular death, particularly in the medium and long term in the intervention group (relative risk (RR) 0.74, 95% confidence interval (CI) 0.64 to 0.86), as well as a reduction in the risk of new hospitalisations (RR 0.82, 95% CI 0.70 to 0.96). Despite a protective tendency, CR failed to demonstrate a significant reduction in total mortality and a reduction in the risk of new MI or new revascularisation procedures. Hinde et al.8 used these recent data to build a decision-analytic model and study the contemporaneous CR programmes’ cost-effectiveness, and also to extrapolate these possible benefits to a lifetime scenario. In order to estimate the impact of socioeconomic status on the health benefits of CR, and knowing that social deprivation is a cardiovascular risk on its own, the authors combined data from the UK Office for National Statistics and the 2017 UK national audit10 to stratify costs and quality-adjusted life years (QALYs) gained according to deprivation indices. The study confirms that CR programmes are still highly cost-effective, as the overall incremental cost-effectiveness ratio (ICER) was below £3500 per QALY, one third of the Claxton threshold to consider cost-effectiveness. When stratified by socioeconomic factors, the authors found that CR programmes were more expensive in deprived areas, and that patients with low socioeconomic status had potentially fewer QALYs to be gained from CR. This can be explained by the lower rates of CR enrolment in these areas, as well as a poorer degree of plan completion and the worst cardiovascular outcomes in this cohort, which skews the model to be less cost-effective (as the budget is spent with no health benefits gained). The authors explored mechanisms to increase the uptake to at least 65%, and despite the high cost estimated to achieve the goal (approximately £68.4 m), this expenditure would be justified by a reduction of approximately 21,000 hospitalisations and more than 8000 deaths avoided over a decade. As we see the emerging of new highly costly and sophisticated cardiovascular therapies, the study highlights the importance of a comparatively low-cost treatments such as the CR programmes. One of its novelties is highlighting the inequalities in terms of CR access, uptake and completion, and evaluating the potential health losses and costs associated with it. These results should be considered carefully by policy makers interested in reducing inequalities in health, as investing in CR programmes may be one of the keys to educate and empower the most vulnerable patients, involving them in their own health and reducing the costs of further adverse events along the way. Within the natural process of developing economic studies, certain assumptions need to be accepted. The study by Hinde et al.8 is based on Anderson’s combination of outcomes from various types of CR programmes. Therefore, the model developed by the authors used a combined odds ratio achieved from a pool of heterogeneous interventions that may have been developed according to dissimilar standards. The nature of the data used also has its own limitation, as it would be interesting to investigate the CR effectiveness stratified by class of CR intervention (for example exercise-only programmes versus more comprehensive approaches). The authors also chose to start the model at 65 years of age, the average age at which the UK national audit describes CR users, but potentially starting the model at an earlier age (56 years of age was the average age in the review by Anderson et al.)9 would probably result in an increase of health benefits with no significant changes in cost, if we assume the long-term benefits are sustained over time. Due to profound differences in CR programmes worldwide, the next frontier will be making sure every programme meets high quality standards, and efforts have been made to standardise the care delivered across Europe recently.11 The need for accreditation and certification of the centres providing cardiac prevention is the next challenge to improve the implementation of CR in clinical practice.1112 Health services should focus on making sure high-quality CR programmes are widely available for their patients as soon as they leave the hospital. Their merits are not limited to reducing cardiovascular risk by increasing exercise uptake, but more importantly their usefulness resides in changing detrimental behaviours and increasing medication compliance, which should qualify CR as one of the cornerstones of the secondary prevention scenario. This therapy should be regarded as crucial as the medical treatment, and its accessibility considered an indicator of high-quality standards in the health system. National audits need to identify the global and regional obstacles in the use of CR and develop solutions adapted to their populations. Particularly in deprived areas, the potential additional investment made in increasing availability and successfully achieving programme completion should be seen not only as cost-effective in the long-term, but also as a channel to reduce socioeconomic disparities in health. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.