Cost-effectiveness of new cardiac and vascular rehabilitation strategies for patients with coronary artery disease.
OBJECTIVE
Peripheral arterial disease (PAD) often hinders the cardiac rehabilitation program. The aim of this study was evaluating the relative cost-effectiveness of new rehabilitation strategies which include the diagnosis and treatment of PAD in patients with coronary artery disease (CAD) undergoing cardiac rehabilitation.


METHODS
Best-available evidence was retrieved from literature and combined with primary data from 231 patients.


METHODS
We developed a markov decision model to compare the following treatment strategies: 1. cardiac rehabilitation only; 2. ankle-brachial index (ABI) if cardiac rehabilitation fails followed by diagnostic work-up and revascularization for PAD if needed; 3. ABI prior to cardiac rehabilitation followed by diagnostic work-up and revascularization for PAD if needed. Quality-adjusted-life years (QALYs), life-time costs (US $), incremental cost-effectiveness ratios (ICER), and gain in net health benefits (NHB) in QALY equivalents were calculated. A threshold willingness-to-pay of $75,000 was used.


RESULTS
ABI if cardiac rehabilitation fails was the most favorable strategy with an ICER of $44,251 per QALY gained and an incremental NHB compared to cardiac rehabilitation only of 0.03 QALYs (95% CI: -0.17, 0.29) at a threshold willingness-to-pay of $75,000/QALY. After sensitivity analysis, a combined cardiac and vascular rehabilitation program increased the success rate and would dominate the other two strategies with total lifetime costs of $30,246 a quality-adjusted life expectancy of 3.84 years, and an incremental NHB of 0.06 QALYs (95%CI:-0.24, 0.46) compared to current practice. The results were robust for other different input parameters.


CONCLUSIONS
ABI measurement if cardiac rehabilitation fails followed by a diagnostic work-up and revascularization for PAD if needed are potentially cost-effective compared to cardiac rehabilitation only.
Spronk
Sandra
S
Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands. s.spronk@erasmusmc.nl
Bosch
Johanna L
JL
Ryjewski
Constance
C
Rosenblum
Judith
J
Kaandorp
Guido C
GC
White
John V
JV
Hunink
M G Myriam
MG
D003324:Coronary Artery Disease / Q000191:economics* / Q000534:rehabilitation*; D003362:Cost-Benefit Analysis; D006262:Health; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D011788:Quality of Life; D012680:Sensitivity and Specificity; D016896:Treatment Outcome; D014481:United States