Abstract
As cardiac rehabilitation (CR) is highly effective, cost-effective, and professionally recommended, policymakers seek to increase utilization. Here we applied results from a randomized trial of case management (CM) and financial incentives (FI), paid as retail gift cards, separately and combined. We modeled their impact and cost-effectiveness compared to usual care (UC) in increasing quality-adjusted life years (QALYs).PURPOSEAs cardiac rehabilitation (CR) is highly effective, cost-effective, and professionally recommended, policymakers seek to increase utilization. Here we applied results from a randomized trial of case management (CM) and financial incentives (FI), paid as retail gift cards, separately and combined. We modeled their impact and cost-effectiveness compared to usual care (UC) in increasing quality-adjusted life years (QALYs).Staff time logs, FI payouts, and CR attendance records generated short-term data. We derived the lifetime QALYs and cost-effectiveness (in 2022 US dollars) from a 2024 cost-effectiveness study of CR calibrated from an observational cohort of 601 099 CR-eligible Medicare beneficiaries. That cohort study controlled for confounding using instrumental variables (IV) and propensity-based (PB) matching.METHODSStaff time logs, FI payouts, and CR attendance records generated short-term data. We derived the lifetime QALYs and cost-effectiveness (in 2022 US dollars) from a 2024 cost-effectiveness study of CR calibrated from an observational cohort of 601 099 CR-eligible Medicare beneficiaries. That cohort study controlled for confounding using instrumental variables (IV) and propensity-based (PB) matching.The FI alone and CM + FI combined interventions increased CR sessions significantly. Additional CR sessions per participant averaged 7.04 (95% CI, 0.93-13.15) with FI and 13.63 (95% CI, 7.86-19.41) with CM + FI. The CM alone intervention did not increase sessions significantly (mean = 1.53: 95% CI, -4.23 to 7.56). The CM + FI intervention generated the most lifetime QALYs, 0.733 (IV) and 1.100 (PB), and displayed a powerful synergy between CM and FI. Under CM + FI, the cost of financial payouts averaged $1088 (range $0-$1966), and total intervention costs averaged $2388. The lifetime cost-effectiveness of CM + FI was 29.966 (95% CI, 29.636-30.296, IV) or 29.257 (95% CI, 28.935-29.579 PB) QALYs/$million. Both values substantially surpassed the average threshold of the United States health care system (10.421 QALYs/$million).RESULTSThe FI alone and CM + FI combined interventions increased CR sessions significantly. Additional CR sessions per participant averaged 7.04 (95% CI, 0.93-13.15) with FI and 13.63 (95% CI, 7.86-19.41) with CM + FI. The CM alone intervention did not increase sessions significantly (mean = 1.53: 95% CI, -4.23 to 7.56). The CM + FI intervention generated the most lifetime QALYs, 0.733 (IV) and 1.100 (PB), and displayed a powerful synergy between CM and FI. Under CM + FI, the cost of financial payouts averaged $1088 (range $0-$1966), and total intervention costs averaged $2388. The lifetime cost-effectiveness of CM + FI was 29.966 (95% CI, 29.636-30.296, IV) or 29.257 (95% CI, 28.935-29.579 PB) QALYs/$million. Both values substantially surpassed the average threshold of the United States health care system (10.421 QALYs/$million).The CM + FI intervention proved highly effective and more than twice as cost-effective as the average of all health interventions in the United States. Thus, CM + FI, combined with other effective interventions such as automatic referral and home-based CR, merit widespread implementation and funding.CONCLUSIONSThe CM + FI intervention proved highly effective and more than twice as cost-effective as the average of all health interventions in the United States. Thus, CM + FI, combined with other effective interventions such as automatic referral and home-based CR, merit widespread implementation and funding.