Vitality Center, Máxima Medical Center, Eindhoven/Veldhoven, Veldhoven, the Netherlands.
Department of Cardiology, Máxima Medical Center, Eindhoven/Veldhoven, Veldhoven, the Netherlands.
JAMA Netw Open. 2021 Dec 1;4(12):e2136652. doi: 10.1001/jamanetworkopen.2021.36652.
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 center-based 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 cost-effectiveness 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], €224 [€4] [$256 ($4)]) compared with center-based CR (mean [SE], €156 [€5] [$178 ($6)]; P < .001); however, no difference in overall cardiac health care costs was observed between CTR (mean [SE], €4787 [€503] [$5467 ($574)] and center-based CR (mean [SE], €5507 [€659] [$6289 ($753)]; P = .36). From a societal perspective, CTR was associated with lower costs compared with center-based CR (mean [SE], €20 495 [€ 2751] [$23 405 ($3142)] vs €24 381 [€3613] [$27 843 ($4126)], respectively), although this difference was not statistically significant (-€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.
重要性：心脏远程康复（CTR）已被证明是传统中心为基础的心脏康复（CR）的一种安全且有益的替代方法，并且可能通过降低 CR 使用障碍而与更高的参与率相关。然而，CR 干预措施的实施仍然很低，这可能是由于缺乏对来自大规模随机临床试验的数据的成本效益分析。
目的：评估与基于中心的 CR 相比，针对冠心病患者的带复发预防的 CTR 的成本效益。
设计、设置和参与者：本经济评估对来自 SmartCare-CAD（使用个性化以患者为中心的 ICT 平台的冠心病患者心脏远程康复的效果）随机临床试验的数据进行了成本效用分析。比较了 3 个月的心脏远程康复加 9 个月的复发预防与传统基于中心的心脏康复的成本效益。分析包括 300 名在荷兰 2 家综合医院的 CR 中心接受治疗的稳定型冠心病患者。所有患者都进入了门诊 CR 的第 2 阶段，随访时间为 1 年（截至 2019 年 8 月 14 日）。数据分析于 2020 年 9 月 21 日至 2021 年 9 月 24 日进行。
干预措施：在获得基线测量值后，将参与者随机按 1:1 的比例分为接受 CTR（干预组）或基于中心的 CR（对照组），使用计算机化的块随机化。在进行了 6 次监督性的中心基础训练后，干预组的患者继续在家中使用心率监测器和加速度计进行训练。患者上传心率和身体活动数据，并在每周与物理治疗师的视频咨询中讨论他们的进展。3 个月后，每周的辅导结束，开始按需辅导以预防复发；患者被指示继续使用可穿戴传感器，如果不遵守干预措施或减少运动或身体活动量，将与他们联系。
主要结果和措施：使用 EuroQol 5 维度 5 水平调查（EQ-5D-5L）和 EuroQol 视觉模拟量表（EQ-VAS）评估质量调整生命年，通过医疗消费问卷、生产力成本问卷和非正式护理问卷（由医疗技术评估研究所设计）测量与心脏相关的医疗保健成本和非医疗保健成本。使用荷兰消费者物价指数将成本转换为 2020 年的价格水平（以欧元计价）（为转换为美元，欧元值乘以 1.142，这是 2020 年的平均汇率）。
结果：在 300 名患者（266 名男性[88.7%]）中，平均（SD）年龄为 60.7（9.5）岁。根据两种效用测量的结果，接受 CTR 与基于中心的 CR 的患者的生活质量在研究期间相当（EQ-5D-5L 的平均差异：-0.004；P=0.82；EQ-VAS 的平均差异：-0.001；P=0.92）。与基于中心的 CR（平均[SE]，€156[€5] [$178（$6）]）相比，CTR 的干预成本明显更高（平均[SE]，€224[€4] [$256（$4）]；P<0.001）；然而，在 CTR（平均[SE]，€4787[€503] [$5467（$574）]和基于中心的 CR（平均[SE]，€5507[€659] [$6289（$753）]）之间，没有观察到整体心脏保健成本的差异；P=0.36）。从社会角度来看，与基于中心的 CR 相比，CTR 与较低的成本相关（平均[SE]，€20495[€2751] [$23405（$3142）]与 €24381[€3613] [$27843（$4126）]，差异无统计学意义（-€3887 [-$4439]；P=0.34）。
结论和相关性：在这项经济评估中，带复发预防的 CTR 干预措施可能比基于中心的 CR 具有成本效益，这表明 CTR 可能被用作冠心病患者治疗的替代干预措施。这些结果增加了支持 CTR 的证据基础，并可能增加 CTR 干预措施在临床实践中的实施。
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