Abstract P371: Estimating Cost-Effectiveness of Exercise Based Cardiac Rehabilitation for Older Patients With Atrial Fibrillation

Abstract

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.