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Introduction: Observational evidence from real world data suggests that providing cardiac rehabilitation (CR) to older patients with incident atrial fibrillation (AF) is associated with lower risk of all-cause mortality and re-hospitalization. We leveraged these data to estimate cost-effectiveness of extending Medicare coverage for exercise based CR to older AF patients. Hypotheses: Exercise based CR for older patients with incident AF is cost-effective at a conventional willingness to pay threshold of $50,000 per quality adjusted life year (QALY). Methods: A cost-utility analysis was conducted using a decision tree to compare initiation of exercise-based CR with standard care versus standard care alone for older patients with incident AF. Outcomes considered were re-hospitalization and all-cause mortality. A systematic review was conducted to obtain inputs for model parameters. Paucity of research did not allow meta-analyses. Estimated risks & related uncertainty intervals for re-hospitalization and death were obtained from a published propensity score matched analysis of electronic health records data pooled from 41 health care organizations in the United States of America and the United Kingdom. In this study, CR + standard care versus standard care alone was associated with lower odds of all-cause mortality (odds ratio, 0.32, 95% uncertainty interval 0.29, 0.35) and re-hospitalization (odds ratio, 0.56, 95% uncertainty interval, 0.53, 0.59) over 18 months of follow-up. Estimations for costs and QALY were obtained from USA based, peer-reviewed, published studies. Probabilistic sensitivity analysis was conducted to account for uncertainty in estimates. Data analysis was performed from healthcare perspective using Microsoft Excel software. Results: In a hypothetical cohort of 10,000 older patients with incident AF (mean age, 68 years, 71% male, 84% White), estimated costs per QALY gained for CR + standard care was about $2659 and standard care alone was about $2455. Providing CR was associated with an estimated incremental cost of $10,374 per incremental QALY gained. Probabilistic sensitivity analysis showed that CR had a >75% chance of being cost-effective at a willingness to pay threshold of $50,000 per QALY. Conclusions: Findings from our simulation study based on real world evidence suggest that extending Medicare coverage for exercise based CR to older patients with incident AF may be potentially cost-effective. Implementing such a policy change requires evidence from a large randomized controlled trial that overcomes design-related limitations identified in previous observational and small, randomized interventional research studies.

A 76 year old lady presented with altered sensorium and was found to have hyperammonemia on evaluation. She had no evidence of liver disease. For her symptomatology of backache, evaluation by bone marrow study showed evidence of multiple myeloma. She was given chemotherapy for multiple myeloma, which resulted in improvement in her sensorium, alongwith this there was also a rapid decline in serum ammonia levels. Hyperviscosity and hypercalcemia are common causes of altered sensorium in a patient with myeloma but in this case hyperammonemia was the likely cause.

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