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Original Investigation
November 24, 2021

Economic Outcomes of Rehabilitation Therapy in Older Patients With Acute Heart Failure in the REHAB-HF Trial: A Secondary Analysis of a Randomized Clinical Trial

Author Affiliations
  • 1Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
  • 2Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
  • 3Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
  • 4Department of Internal Medicine, Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 5Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 6Doctor of Physical Therapy Division, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina
  • 7Novant Health Heart and Vascular Institute, Charlotte, North Carolina
  • 8Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 9Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 10Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
JAMA Cardiol. Published online November 24, 2021. doi:10.1001/jamacardio.2021.4836
Key Points

Question  What are the economic outcomes of the Rehabilitation Therapy in Older Acute Heart Failure Patients trial, which randomized older patients admitted for acute decompensated heart failure to a novel rehabilitation intervention vs control?

Findings  In this secondary analysis of a randomized clinical trial including 349 patients, mean medical costs were similar in both groups, surpassing $25 000 per patient by 6 months, but quality-of-life gains were greater in the rehabilitation intervention group. Lifetime cost-effectiveness ratios for the intervention varied, but most were within conventional benchmarks for good value when simulated using the validated Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model.

Meaning  These findings suggest that initiating rehabilitation training in older patients hospitalized for acute decompensated heart failure may yield good economic value to the US health care system.

Abstract

Importance  In the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a novel 12-week rehabilitation intervention demonstrated significant improvements in validated measures of physical function, quality of life, and depression, but no significant reductions in rehospitalizations or mortality compared with a control condition during the 6-month follow up. The economic implications of these results are important given the increasing pressures for cost containment in health care.

Objective  To report the economic outcomes of the REHAB-HF trial and estimate the potential cost-effectiveness of the intervention.

Design, Setting, Participants  The multicenter REHAB-HF trial randomized 349 patients 60 years or older who were hospitalized for acute decompensated heart failure to rehabilitation intervention or a control group; patients were enrolled from September 17, 2014, through September 19, 2019. For this preplanned secondary analysis of the economic outcomes, data on medical resource use and quality of life (via the 5-level EuroQol 5-Dimension scores converted to health utilities) were collected. Medical resource use and medication costs were estimated using 2019 US Medicare payments and the Federal Supply Schedule, respectively. Cost-effectiveness was estimated using the validated Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model, which uses an individual-patient simulation model informed by the prospectively collected trial data. Data were analyzed from March 24, 2019, to December 1, 2020.

Interventions  Rehabilitation intervention or control.

Main Outcomes and Measures  Costs, quality-adjusted life-years (QALYs), and the lifetime estimated cost per QALY gained (incremental cost-effectiveness ratio).

Results  Among the 349 patients included in the analysis (183 women [52.4%]; mean [SD] age, 72.7 [8.1] years; 176 non-White [50.4%] and 173 White [49.6%]), mean (SD) cumulative costs per patient were $26 421 ($38 955) in the intervention group (excluding intervention costs) and $27 650 ($30 712) in the control group (difference, −$1229; 95% CI, −$8159 to $6394; P = .80). The mean (SD) cost of the intervention was $4204 ($2059). Quality of life gains were significantly greater in the intervention vs control group during 6 months (mean utility difference, 0.074; P = .001) and sustained beyond the 12-week intervention. Incremental cost-effectiveness ratios were estimated at $58 409 and $35 600 per QALY gained for the full cohort and in patients with preserved ejection fraction, respectively.

Conclusions and Relevance  These analyses suggest that longer-term benefits of this novel rehabilitation intervention, particularly in the subgroup of patients with preserved ejection fraction, may yield good value to the health care system. However, long-term cost-effectiveness is currently uncertain and dependent on the assumption that benefits are sustained beyond study follow-up, which needs to be corroborated in future trials in this patient population.

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