Current issues of ACP Journal Club are published in Annals of Internal Medicine


Economics

Exercise and behavioral rehabilitation soon after myocardial infarction was cost-effective

ACP J Club. 1994 Jan-Feb;120:26. doi:10.7326/ACPJC-1994-120-1-026


Source Citation

Oldridge N, Furlong W, Feeny D, et al. Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction. Am J Cardiol. 1993 Jul 15;72:154-61.


Abstract

Objective

To determine the cost-effectiveness and cost-utility of an 8-week combined exercise and behavioral rehabilitation intervention initiated within 6 weeks of an acute myocardial infarction (MI) in patients with moderate anxiety or depression.

Design

Cost-effectiveness and cost-utility analyses in a 12-month randomized controlled trial.

Setting

Area in and surrounding Hamilton, Ontario, Canada.

Patients

201 patients (mean age 53 y, 89% men) with acute MIs who were moderately anxious or depressed while in the hospital. Patients were excluded who scored < 5 on the short Beck Depression Inventory, < 43 on the Spielberger State Anxiety Inventory, or < 42 on the Spielberger Trait Anxiety Inventory.

Intervention

99 patients were allocated to an 8-week rehabilitation intervention and 102 were allocated to usual care. The 8-week rehabilitation program consisted of supervised low-level exercise and group behavioral and risk factor management counseling that focused on coping strategies.

Main cost and outcome measures

Monetary costs of the rehabilitation intervention, patient-borne costs, and differences in health-care services utilization in patients receiving either rehabilitation or usual care, as well as changes in health-related quality of life. Cost information was combined with time trade-off measures of health-related quality of life to estimate the cost-utility of cardiac rehabilitation.

Main results

The rehabilitation program was associated with an accelerated recovery in some health-related outcomes at 8 weeks. However, at 12 months, similar improvements were observed in disease-specific measures, in generic health-related quality-of-life measures, and in other outcome measures, including mortality and return-to-work rates. The best estimate of the net incremental direct 12-month cost of the rehabilitation program was $480 per patient. Assuming equal survivals and using the differences in mean time trade-off change scores, the best estimate of quality-adjusted life-years gained per patient was 0.052 (95% CI 0.007 to 0.100). The cost per quality-adjusted life-year gained with rehabilitation was $9200.

Conclusion

An 8-week combined exercise and behavioral rehabilitation intervention initiated within 6 weeks of acute myocardial infarction in patients with moderate anxiety or depression was a relatively efficient use of health-care resources.

Source of funding: Health and Welfare, Canada.

For article reprint: Dr. N. Oldridge, Indiana University Center for Aging Research, Regenstrief Institute for Health Care, 1001 West Tenth Street, RG6, Indianapolis, Indiana, 46202-2859, USA. FAX 317-630-6611.


Commentary

Cardiac rehabilitation prolongs life (1) and may offer economic benefits to survivors of MI, such as an earlier return to work (2). The study by Oldridge and colleagues shows that cardiac rehabilitation is also a low-cost means of making modest improvements in the self-assessed quality of life of anxious or depressed survivors of MI.

The primary outcome measure, a time trade-off rating, is harder to interpret than a familiar concept like mortality. Changes in this measure could reflect alterations in attitudes, and could improve even if the intervention does not prevent recurrent symptoms of coronary disease, hasten recovery of functional status, or alleviate activity limitations.

It is difficult to make generalizations from any single study of cardiac rehabilitation because different programs include different services. The chief components of this program were supervised exercise and counseling designed to modify behavior and risk factors. Often a single, inexpensive component of a complex intervention accounts for much of the effectiveness; other components may be costly or ineffective. The investigators did not report on the effect of each part of the intervention, nor was it always clear whether a given cost was part of the counseling or of the exercise component. Some features of the intervention may have been highly cost-effective, whereas others may not have been.

This study reinforces evidence that cardiac rehabilitation is a cost-effective approach to the management of anxious and depressed survivors of MI. To assess the generality of these results and to refine our approaches to cardiac rehabilitation, however, we need to learn more about the distinctive contributions that risk factor modification, exercise, and other forms of behavioral modification make to costs and outcomes.

Alan M. Garber, MD
Department of Veterans Affairs and Stanford UniversityPalo Alto, California, USA


References

1. O'Connor GT, Buring JE, Yusuf S, et al. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation. 1989;80:234-44.

2. Picard MH, Dennis C, Schwartz RG, et al. Cost-benefit analysis of early return to work after uncomplicated acute myocardial infarction. Am J Cardiol. 1989;63:1308-14.