EU-CaRE study: Could exercise-based cardiac telerehabilitation also be cost-effective in elderly?

BACKGROUND: The role of cardiac rehabilitation (CR) is well established in the secondary prevention of ischemic heart disease. Unfortunately, the participation rates across Europe remain low, especially in elderly. The EU-CaRE RCT investigated the effectiveness of a home-based mobile CR programme in elderly patients that were not willing to participate in centre-based CR. The initial study concluded that a 6-month home-based mobile CR programme was safe and beneficial in improving VO2peak when compared with no CR. OBJECTIVE: To assess whether a 6-month guided mobile CR programme is a cost-effective therapy for elderly patients who decline participation in CR. METHODS: Patients were enrolled in a multicentre randomised clinical trial from November 11, 2015, to January 3, 2018, and follow-up was completed on January 17, 2019, in a secondary care system with 6 cardiac institutions across 5 European countries. A total of 179 patients who declined participation in centre-based CR and met the inclusion criteria consented to participate in the European Study on Effectiveness and Sustainability of Current Cardiac Rehabilitation Programs in the Elderly trial. The data of patients (n = 17) that were lost in follow-up were excluded from this analysis. The intervention (n = 79) consisted of 6 months of mobile CR programme with telemonitoring, and coaching based on motivational interviewing to stimulate patients to reach exercise goals. Control patients did not receive any form of CR throughout the study period. The costs considered for the cost-effectiveness analysis of the RCT are direct costs 1) of the mobile CR programme, and 2) of the care utilisation recorded during the observation time from randomisation to the end of the study. Costs and outcomes (utilities) were compared by calculation of the incremental cost-effectiveness ratio. RESULTS: The healthcare utilisation costs (P = 0.802) were not significantly different between the two groups. However, the total costs were significantly higher in the intervention group (P = 0.040). The incremental cost-effectiveness ratio for the primary endpoint VO2peak at 6 months was €1085 per 1-unit [ml/kg/min] improvement in change VO2peak and at 12 months it was €1103 per 1 unit [ml/kg/min] improvement in change VO2peak. Big differences in the incremental cost-effectiveness ratios for the primary endpoint VO2peak at 6 months and 12 months were present between the adherent participants and the non-adherent participants. CONCLUSION: From a health-economic point of view the home-based mobile CR programme is an effective and cost-effective alternative for elderly cardiac patients who are not willing to participate in a regular rehabilitation programme to improve cardiorespiratory fitness. The change of QoL between the mobile CR was similar for both groups. Adherence to the mobile CR programme plays a significant role in the cost-effectiveness of the intervention. Future research should focus on the determinants of adherence, on increasing the adherence of patients and the implementation of comprehensive home-based mobile CR programmes in standard care.

Recommendations on how to provide cardiac rehabilitation services during the COVID-19 pandemic.

The ongoing coronavirus disease 2019 (COVID-19) crisis is having a large impact on acute and chronic cardiac care. Due to public health measures and the reorganisation of outpatient cardiac care, traditional centre-based cardiac rehabilitation is currently almost impossible. In addition, public health measures are having a potentially negative impact on lifestyle behaviour and general well-being. Therefore, the Working Group of Cardiovascular Prevention and Rehabilitation of the Dutch Society of Cardiology has formulated practical recommendations for the provision of cardiac rehabilitation during the COVID-19 pandemic, by using telerehabilitation programmes without face-to-face contact based on current guidelines supplemented with new insights and experiences.

Cardiac telerehabilitation as an alternative to centre-based cardiac rehabilitation.

Multidisciplinary cardiac rehabilitation (CR) reduces morbidity and mortality and increases quality of life in cardiac patients. However, CR utilisation rates are low, and targets for secondary prevention of cardiovascular disease are not met in the majority of patients, indicating that secondary prevention programmes such as CR leave room for improvement. Cardiac telerehabilitation (CTR) may resolve several barriers that impede CR utilisation and sustainability of its effects. In CTR, one or more modules of CR are delivered outside the environment of the hospital or CR centre, using monitoring devices and remote communication with patients. Multidisciplinary CTR is a safe and at least equally (cost-)effective alternative to centre-based CR, and is therefore recommended in a recent addendum to the Dutch multidisciplinary CR guidelines. In this article, we describe the background and core components of this addendum on CTR, and discuss its implications for clinical practice and future perspectives.

Long-term clinical outcome of patients with diabetes proposed for coronary revascularisation.

BACKGROUND: The optimal method of revascularisation in diabetic patients with coronary artery disease (CAD) remains controversial. It was our aim to evaluate long-term outcome in diabetic patients with CAD in daily practice, in whom an invasive approach was considered. METHODS: A prospective follow-up study of patients with CAD in whom a coronary revascularisation procedure was considered. Follow-up data were obtained on the vital status up to ten years after inclusion. RESULTS: Of the 872 included patients, a total of 107 patients (12%) had diabetes. Patients with diabetes were older and more frequently female. Long-term mortality was higher in diabetics than nondiabetics (36 vs 25%, p = 0.01). This association was observed in both medically treated patients (65 vs 31%, p = 0.01) and in those treated by percutaneous coronary intervention (41 vs 24%, p = 0.02). There was, however, no difference in mortality in diabetes vs nondiabetes patients after coronary artery bypass grafting (24 vs 24%, p = 0.89). Multivariate analysis did not change these findings. CONCLUSION: Diabetic patients with significant CAD had a higher long-term mortality compared with patients without diabetes. In patients with diabetes, survival was highest after coronary artery bypass grafting and appeared to be comparable between diabetic and nondiabetic patients. Complete revascularisation may decrease the influence of diabetes on survival.

[Infection and superior vena cava syndrome after pacemaker implantations: major consequences of a minor intervention]. / Infectie en V.-cava-superior syndroom na pacemakerimplantaties: grote gevolgen van een kleine ingreep.

Two men, aged 71 and 56 years, with pacemakers, developed the superior vena cava syndrome one and five years, respectively, after infection of the pacemaker pocket. They had been treated with antibiotics and partial removal of the foreign bodies. The conditions of both included occlusion of the superior vena cava and of both subclavian veins. The symptoms disappeared after removal of the total pacemaker system and venous reconstruction. The possibility of a superior vena cava syndrome occurring is increased if other complications have occurred previously, particularly infection. Prevention and treatment comprise on the one hand prevention and treatment of the infection (which is not always obvious) and on the other, earliest possible detection of thromboembolisms.

[Free admission to stress electrocardiography with subsequent cardiological advice and feedback to the family physician: favorable effect on referral patterns]. / Vrije toegang tot inspanningselektrocardiografie met aansluitend cardiologisch advies en feedback aan de huisarts: gunstige invloed op het verwijspatroon.

OBJECTIVE: To improve the patient referral by general practitioners to the cardiology outpatient clinic for evaluation of (possibly) anginal complaints, by giving access to in-hospital bicycle exercise testing with cardiological advice and feedback. DESIGN: Prospective. SETTING: Department of non-invasive cardiology 'De Weezenlanden' Hospital, Zwolle, the Netherlands. METHODS: Patients, with no cardiological history, were collected from two comparable groups of general practitioners: an experimental group (n = 90.000 patients), allowed to perform an in-hospital exercise test with concomitant advice of a cardiologist, and a reference group (n = 53.400 patients), who referred directly to the cardiologist without having this facility (as customary in the Dutch health care system). Data were collected prospectively from January 1st 1994 until May 1st 1995. RESULTS: In the experimental group, 615 patients underwent exercise tests; 100 were subsequently referred. In addition, 53 patients were referred directly (total 153 patients; 1.3/1000 patients/year; 95% confidence interval: 1.1-1.5). In 51% of referred patients coronary disease was present, 37% underwent coronary angiography and 23% revascularisation (PTCA or CABG). During follow-up for 2 months no cardiovascular events occurred in non-referred patients. In the reference group, 132 patients were referred directly (1.9/1000 patients/ year; 1.6-2.2; p < 0.01 when compared with the experimental group). Of these patients 13% had coronary disease, 8% underwent coronary angiography and 3% revascularisation. CONCLUSION: Free access to exercise testing with cardiological advice and feedback for general practitioners resulted in a reduction of referrals with improved efficiency.