Costs and effectiveness of cardiac rehabilitation for dialysis patients following coronary bypass

Cluster Randomized Controlled Trial on the Effects of 12 Months of Combined Exercise Training during Hemodialysis in Patients with Chronic Kidney Disease-Study Protocol of the Dialysis Training Therapy (DiaTT) Trial

Patients with chronic kidney disease (CKD) on hemodialysis (HD) experience treatment-related immobility and physical deconditioning, which is responsible for an increased risk of frailty and a high burden of multi-morbidity. Exercise has been shown to counteract this vicious cycle; however, its effectiveness has only been investigated in small cohorts. Therefore, the objective of the Dialysis Training Therapy (DiaTT) trial will be to assess the effects of a 12-month intradialytic exercise program on physical functioning, frailty and health economics in a large cohort of HD patients in a real-world setting. DiaTT will be a prospective, cluster-randomized (1:1), controlled, multi-center, interventional clinical trial across 28 dialysis units, aiming at the recruitment of >1100 CKD patients on HD. The intervention group will receive 12 months’ intradialytic exercise (combined aerobic and resistance training), whereas the usual care group will not receive intervention. The primary endpoint will be a change on the sit-to-stand test (STS60) result between baseline and 12 months. Secondary endpoints will include physical functioning, frailty, quality of life, 3-point MACE, hospitalizations, survival, quality of HD, health literacy and health care costs. By including almost as many patients as previously investigated in smaller trials, DiaTT will be the largest randomized, controlled trial assessing frailty, quality of life and mortality in the field of nephrology.

A Cost-Effective Analysis of the CYCLE-HD Randomized Controlled Trial

Introduction

No formal cost-effectiveness analysis has been performed for programs of cycling exercise during dialysis (intradialytic cycling [IDC]). The objective of this analysis is to determine the effect of a 6-month program of IDC on health care costs.

Methods

This is a retrospective formal cost-effectiveness analysis of adult participants with end-stage kidney disease undertaking in-center maintenance hemodialysis enrolled in the CYCLE-HD trial. Data on hospital utilization, primary care consultations, and prescribed medications were extracted from medical records for the 6 months before, during, and after a 6-month program of thrice-weekly IDC. The cost-effectiveness analysis was conducted from a health care service perspective and included the cost of implementing the IDC intervention. The base-case analyses included a 6-month “within trial” analysis and a 12-month “within and posttrial” analysis considering health care utilization and quality of life (QoL) outcomes.

Results

Data from the base-case within trial analysis, based on 109 participants (n = 56 control subjects and n = 53 IDC subjects) showed a reduction in health care utilization costs between groups, favoring the IDC group, and a 73% chance of IDC being cost-effective compared with control subjects at a willingness to pay of £20,000 and £30,000 per quality-adjusted life year (QALY) gained. When QoL data points were extrapolated forward to 12 months, the probability of IDC being cost-effective was 93% and 94% at £20,000 and £30,000 per QALY gained. Sensitivity analysis broadly confirms these findings.

Conclusion

A 6-month program of IDC is cost-effective and the implementation of these programs nationally should be a priority.

Economic Evaluations Informed Exclusively by Real World Data: A Systematic Review

Economic evaluations using Real World Data (RWD) has been increasing in the very recent years, however, this source of information has several advantages and limitations. The aim of this review was to assess the quality of full economic evaluations (EE) developed using RWD. A systematic review was carried out through articles from the following databases: PubMed, Embase, Web of Science and Centre for Reviews and Dissemination. Included were studies that employed RWD for both costs and effectiveness. Methodological quality of the studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Of the 14,011 studies identified, 93 were included. Roughly half of the studies were carried out in a hospital setting. The most frequently assessed illnesses were neoplasms while the most evaluated interventions were pharmacological. The main source of costs and effects of RWD were information systems. The most frequent clinical outcome was survival. Some 47% of studies met at least 80% of CHEERS criteria. Studies were conducted with samples of 100-1000 patients or more, were randomized, and those that reported bias controls were those that fulfilled most CHEERS criteria. In conclusion, fewer than half the studies met 80% of the CHEERS checklist criteria.

Usefulness of frailty evaluation for handling chronic kidney disease elderly patients: a review and original proposal

There is interdependence between chronic kidney disease (CKD) and ageing whereby CKD makes ageing more accelerated and pronounced, whereas ageing accelerates chronic nephropathy's progression. Frailty status catalyzes this spiral, with renal and systemic negative consequences, and this condition can currently be documented by applying already validated clinical scores (frailty phenotype) or physical test (gate speed). Although, nephroprevention strategies are similar between young adult and senior CKD patients, standard targets should be adequate to very old and frail elderly individuals. For this purpose, an original algorithm is here proposed to adjust the conventional nephroprevention strategies to the condition of CKD frail patient (more relaxed targets and tighter control), as well as to prescribe anti-frailty interventions to slow patient's functional decline, hospitalization and mortality.

Cost-effectiveness of cardiac rehabilitation: a systematic review

Patients may be offered cardiac rehabilitation (CR), a supervised programme often including exercises, education and psychological care, following a cardiac event, with the aim of reducing morbidity and mortality. Cost-constrained healthcare systems require information about the best use of budget and resources to maximise patient benefit. We aimed to systematically review and critically appraise economic studies of CR and its components. In January 2016, validated electronic searches of the National Health Service Economic Evaluation Database (NHS EED), Health Technology Assessment, PsycINFO, MEDLINE and Embase databases were run to identify full economic evaluations published since 2001. Two levels of screening were used and explicit inclusion criteria were applied. Prespecified data extraction and critical appraisal were performed using the NHS EED handbook and Drummond checklist. The majority of studies concluded that CR was cost-effective versus no CR (incremental cost-effectiveness ratios (ICERs) ranged from $1065 to $71 755 per quality-adjusted life-year (QALY)). Evidence for specific interventions within CR was varied; psychological intervention ranged from dominant (cost saving and more effective) to $226 128 per QALY, telehealth ranged from dominant to $588 734 per QALY and while exercise was cost-effective across all relevant studies, results were subject to uncertainty. Key drivers of cost-effectiveness were risk of subsequent events and hospitalisation, hospitalisation and intervention costs, and utilities. This systematic review of studies evaluates the cost-effectiveness of CR in the modern era, providing a fresh evidence base for policy-makers. Evidence suggests that CR is cost-effective, especially with exercise as a component. However, research is needed to determine the most cost-effective design of CR.

Therapy Caps and Variation in Cost of Outpatient Occupational Therapy by Provider, Insurance Status, and Geographic Region

OBJECTIVE

This article describes the cost of occupational therapy by provider, insurance status, and geographic region and the number of visits allowed and out-of-pocket costs under proposed therapy caps.

METHOD

This retrospective, population-based study used Medicare Provider Utilization and Payment Data for occupational therapists billing in 2012 and 2013 (Ns = 3,662 and 3,820, respectively). We examined variations in outpatient occupational therapy services with descriptive statistics and the impact of therapy caps on occupational therapy visits and patient out-of-pocket costs.

RESULTS

Differences in cost between occupational and physical therapists were minimal. The most frequently billed service was therapeutic exercises. Wisconsin had the most inflated outpatient costs in both years. Under the proposed therapy cap, patients could receive an evaluation plus 12-14 visits.

DISCUSSIO

. Wide variation exists in potential patient out-of-pocket costs for occupational therapy services on the basis of insurance coverage and state. Patients without insurance pay a premium.

Senescent Nephropathy: The New Renal Syndrome

Chronic kidney disease (CKD) is a condition characterized by progressive and irreversible deterioration of renal function due to the reduction of nephron mass for a period of at least three months. The prevalence of CKD is roughly 10% in the general population but increases with age, affecting more than one-third of people older than 65. Frailty is a condition usually found in elderly people, characterized by weakness, motility, and balance issues, with a declined ability to resist stressors leading to increased risks of adverse health outcomes including falls, fracture, hospitalization, institutionalization, disability, dependence, dementia, poor quality of life, and death. There is interdependence between CKD and normal ageing whereby CKD makes ageing more accelerated and pronounced (senescence), whereas senescence accelerates chronic nephropathy’s progression. Frailty status catalyzes this spiral, with renal and systemic consequences, phenomenon which can be named senescent nephropathy. In conclusion, senescent nephropathy is a new renal syndrome that should be taken into account, and we must try to handle its appearance and progression not only by applying nephron prevention measurements but also by diagnosis and treating frailty in the CKD population.

The cost-effectiveness of exercise-based cardiac rehabilitation: a systematic review of the characteristics and methodological quality of published literature

AIM

This descriptive review aimed to assess the characteristics and methodological quality of economic evaluations of cardiac rehabilitation (CR) programs according to updated economic guidelines for healthcare interventions. Recommendations will be made to inform future research addressing the impact of a physical exercise component on cost-effectiveness.

METHODS

Electronic databases were searched for economic evaluations of exercise-based CR programs published in English between 2000 and 2014. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement was used to review the methodological quality of included economic evaluations.

RESULTS

Fifteen economic evaluations met the review inclusion criteria. Assessed study characteristics exhibited wide variability, particularly in their economic perspective, time horizon, setting, comparators and included costs, with significant heterogeneity in exercise dose across interventions. Ten evaluations were based on randomised controlled trials (RCTs) spanning 6-24 months but often with weak or inconclusive results; two were modelling studies; and the final three utilised longer time horizons of 3.5-5 years from which findings suggest that long-term exercise-based CR results in lower costs, reduced hospitalisations and a longer cumulative patient lifetime. None of the 15 articles met all the CHEERS quality criteria, with the majority either fully or partially meeting a selection of the assessed variables.

CONCLUSION

Evidence exists supporting the cost-effectiveness of exercise-based CR for cardiovascular disease patients. However, variability in CR program delivery and weak consistency between study perspective and design limits study comparability and therefore the accumulation of evidence in support of a particular exercise regime. The generalisability of study findings was limited due to the exclusion of patients with comorbidities as would typically be found in a real-world setting. The use of longer time-horizons would be more comparable with a chronic condition and enable economic assessments of the long-term effects of CR. As none of the articles met recent reporting standards for the economic assessment of healthcare interventions, it is recommended that future studies adhere to such guidelines.

Narrative review comparing the benefits of and participation in cardiac rehabilitation in high-, middle- and low-income countries

BACKGROUND

Cardiovascular disease is a leading cause of morbidity worldwide. Cardiac rehabilitation (CR) is a comprehensive secondary prevention approach, with established benefits in reducing morbidity in high-income countries (HICs). The objectives of this review were to summarise what is known about the benefits of CR, including consideration of cost-effectiveness, in addition to rates of CR participation and adherence in high-, as well as low- and middle-income countries (LMICs).

METHODS

A literature search of Medline, Excerpta Medica Database (EMBASE), and Google Scholar was conducted for published articles from database inception to October 2013. The search was first directed to identify meta-analyses and reviews reporting on the benefits of CR. Then, the search was focussed to identify articles reporting CR participation and dropout rates. Full-text versions of relevant abstracts were summarised qualitatively.

RESULTS

Based on meta-analysis, CR significantly reduced all-cause mortality by 13%-26%, cardiac mortality by 20%-36%, myocardial re-infarction by 25%-47%, and risk factors. CR is cost-effective in HICs. In LMICs, CR is demonstrated to reduce risk factors, with no studies on mortality or cost-effectiveness. Based on available data, CR participation rates are <50% in the majority of countries, with documented dropout rates up to 56% and 82% in high- and middle-income countries, respectively.

CONCLUSIONS

CR is a beneficial intervention for heart patients in high and LMICs, but is underutilised with low participation and adherence rates worldwide. While more research is needed in LMICs, strategies shown to increase participation and program adherence should be implemented.

Improving cardiac rehabilitation attendance and completion through quality improvement activities and a motivational program

PURPOSE

Recent studies have demonstrated that patients who attend more cardiac rehabilitation (CR) sessions have lower subsequent mortality rates than those who attend fewer sessions.

METHODS

We analyzed the impact of several phased-in policy and process changes implemented to increase patient participation in CR. In March 2010, our CR program changed from a policy of individualizing the recommended number of CR sessions per patient to a policy that recommended all 36 CR sessions. In October 2010, we introduced a 7-minute video describing the benefits of CR. In August 2011, we introduced a motivational program that rewarded patients after every sixth CR session. The number of CR sessions attended was determined through review of billing records. Enrollment and completion were defined as attending ≥1 session and ≥30 sessions, respectively.

RESULTS

We identified 1103 patients sequentially enrolled in CR between May 2009 and January 2012. Overall, the median number of sessions per patient improved from 12 to 20 (P < .001). Completion rate improved from 14% to 39% (P < .001). The motivational program increased attendance by a median of 3 sessions per patient (P = .04), but this effect was limited to local CR participants. Financial analysis suggested that for every $100 spent on motivational rewards, patients attended an additional 6.6 (95% CI, -1 to 14) sessions of CR.

CONCLUSIONS

Quality improvement activities significantly increased CR participation. Wide implementation of such programs may favorably impact patient participation in CR and potentially decrease the rate of subsequent cardiac events.

Changes in waist circumference following haemodialysis: a brief report

BACKGROUND

Waist circumference (WC) is a known indicator of cardiovascular disease in the haemodialysis (HD) population. However it is not known if HD results in clinically significant changes in WC.

OBJECTIVE

The study purpose was to quantify the degree of change in WC induced by HD.

METHODS

This was a prospective cohort study with 27 patients on HD. Height, body weight, WC, hip circumference (HC), body mass index (BMI) and waist to hip ratio (WHR) were measured immediately prior to and following HD over three consecutive treatments. Differences between three-day average pre- and post-HD weight, BMI, WC, HC and WHR were assessed.

RESULTS

Post-HD WC was significantly lower than that measured pre-HD. Differences in pre-post HD body weight, BMI, HC and WHR were also observed.

CONCLUSIONS

All of the traditional clinical indicators of body composition (WC, HC, WHR, body weight and BMI) were lower following HD.

A systematic review of economic evaluations of cardiac rehabilitation

Background

Cardiac rehabilitation (CR), a multidisciplinary program consisting of exercise, risk factor modification and psychosocial intervention, forms an integral part of managing patients after myocardial infarction (MI), revascularization surgery and percutaneous coronary interventions, as well as patients with heart failure (HF). This systematic review seeks to examine the cost-effectiveness of CR for patients with MI or HF and inform policy makers in Singapore on published cost-effectiveness studies on CR.

Methods

Electronic databases (EMBASE, MEDLINE, NHS EED, PEDro, CINAHL) were searched from inception to May 2010 for published economic studies. Additional references were identified through searching bibliographies of included studies. Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Quality assessment of economic evaluations was undertaken using Drummond’s checklist.

Results

A total of 22 articles were selected for review. However five articles were further excluded because they were cost-minimization analyses, whilst one included patients with stroke. Of the final 16 articles, one article addressed both centre-based cardiac rehabilitation versus no rehabilitation, as well as home-based cardiac rehabilitation versus no rehabilitation. Therefore, nine studies compared cost-effectiveness between centre-based supervised CR and no CR; three studies examined that between centre- and home based CR; one between inpatient and outpatient CR; and four between home-based CR and no CR. These studies were characterized by differences in the study perspectives, economic study designs and time frames, as well as variability in clinical data and assumptions made on costs. Overall, the studies suggested that: (1) supervised centre-based CR was highly cost-effective and the dominant strategy when compared to no CR; (2) home-based CR was no different from centre-based CR; (3) no difference existed between inpatient and outpatient CR; and (4) home-based programs were generally cost-saving compared to no CR.

Conclusions

Overall, all the studies supported the implementation of CR for MI and HF. However, comparison across studies highlighted wide variability of CR program design and delivery. Policy makers need to exercise caution when generalizing these findings to the Singapore context.

A Nontraditional Approach to Cardiac Rehabilitation in the Dialysis Center for a Patient with End-stage Renal Disease Following Coronary Artery Bypass Surgery: A Case Report

BACKGROUND AND PURPOSE

Cardiac rehabilitation (CR) promotes positive outcomes following coronary artery bypass grafting (CABG) surgery. Patients with end-stage renal disease (ESRD), who have an increased risk of cardiac mortality and mobility, have also experienced positive outcomes following CABG. However, participation in CR continues to be limited due to lack of physician referrals, patient compliance, accessibility, and time. Can a CR program be implemented safely and effectively following CABG in a patient during dialysis sessions?

CASE DESCRIPTION

The patient was a 43-year-old male with a history of: ESRD requiring hemodialysis (HD), CABG, hypertension (HTN), and hyperlipidemia. During HD treatments, the patient received CR that included aerobic exercise and education for 16 weeks (26 visits) under the supervision of a physical therapist.

OUTCOMES

The patient gained improvements in: 2-minute walk distance, quality of life (QOL), based on the Short Form-36 (SF-36), and a reduction in modifiable cardiac risk factors. No adverse events occurred during the intervention.

DISCUSSION

A 16-week CR program was implemented safely and effectively following CABG in a patient undergoing concurrent dialysis. This patient demonstrated improved outcomes comparable to patients who receive traditional cardiac rehabilitation following CABG.

Deficient counseling on physical activity among nephrologists

BACKGROUND

An evaluation of exercise counseling practices among nephrologists in 2001 demonstrated few clinicians assessing patients' levels of physical activity (PA) and counseling to increase activity. Recent Kidney Disease Outcomes Quality Initiative (KDOQI) cardiovascular guidelines recommended that nephrologists counsel patients to increase PA. Our objective was to ascertain whether nephrologists' counseling practices have changed.

METHODS

We administered a 30-item survey regarding exercise counseling to nephrologists attending the ASN meeting in 2007. Some questions were adapted from a prior survey administered in 2001 to assess differences in practice patterns compared to 6 years earlier.

RESULTS

Participants answered questions regarding opinions and practices relevant to PA (n = 198), KDOQI guidelines, self-reported PA, and demographic information (n = 173). Participants were 44 ± 11 years of age, 48% practicing in the USA, and 76% male. In multivariate analysis, older nephrologists (OR; 95% CI) (3.3; 1.2-9.0) and those more physically active (5.5; 2.0-14) were more likely to ask and counsel patients about PA. Opinions associated with less counseling behavior included lack of confidence in ability to discuss PA (0.2; 0.05-0.5). Multivariate comparison to previous respondents (n = 503) showed current nephrologists were not asking and counseling more (1.2; 0.81-1.8).

CONCLUSION

Despite new guidelines, counseling behavior has not increased. Published guidelines are insufficient to reach younger nephrologists.

Implementing exercise: what do we know? Where do we go?

Exercise capacity, physical functioning, and physical activity are all low in patients with CKD treated with dialysis. Although there is robust evidence that these patients benefit from regular exercise training and/or increasing physical activity, the nephrology community has not adopted recommendations and encouragement for physical activity as a part of the routine care plan. This article reviews what is known regarding the implementation of exercise and provides suggestions as to how exercise counseling might become a routine part of the care of patients with CKD.

Functional status of elderly adults before and after initiation of dialysis

BACKGROUND

It is unclear whether functional status before dialysis is maintained after the initiation of this therapy in elderly patients with end-stage renal disease (ESRD).

METHODS

Using a national registry of patients undergoing dialysis, which was linked to a national registry of nursing home residents, we identified all 3702 nursing home residents in the United States who were starting treatment with dialysis between June 1998 and October 2000 and for whom at least one measurement of functional status was available before the initiation of dialysis. Functional status was measured by assessing the degree of dependence in seven activities of daily living (on the Minimum Data Set-Activities of Daily Living [MDS-ADL] scale of 0 to 28 points, with higher scores indicating greater functional difficulty).

RESULTS

The median MDS-ADL score increased from 12 during the 3 months before the initiation of dialysis to 16 during the 3 months after the initiation of dialysis. Three months after the initiation of dialysis, functional status had been maintained in 39% of nursing home residents, but by 12 months after the initiation of dialysis, 58% had died and predialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status, indicated by an increase of 2.8 points in the MDS-ADL score (95% confidence interval [CI], 2.5 to 3.0); this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial (1.7 points; 95% CI, 1.4 to 2.1), even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis.

CONCLUSIONS

Among nursing home residents with ESRD, the initiation of dialysis is associated with a substantial and sustained decline in functional status.