Cost-Effectiveness of Cardiac Telerehabilitation With Relapse Prevention for CAD

Quick Takes

  • Cardiac telerehabilitation with extended remote monitoring relapse prevention is likely to be a cost-effective alternative to conventional center-based CR among patients with stable CAD, and following an acute coronary syndrome and/or coronary revascularization.
  • The validation of cost-benefit of extending center-based CR with remote monitoring and additional patient education using total costs was unique. Total societal cost-benefit by adding extended telehealth to standard CR included health care and non–health care costs (example, work productivity costs).

Study Questions:

Is cardiac telerehabilitation (CTR) for relapse prevention cost-effective compared with center-based cardiac rehabilitation (CR) among patients with coronary artery disease (CAD)?


A cost-utility analysis of data from a randomized clinical trial of 3 months of CTR followed by 9 months of relapse prevention was compared with the cost-effectiveness of traditional center-based CR serving two hospitals in the Netherlands. The analysis included 300 patients entering phase 2 who were referred for CR including stable CAD, and patients following an acute coronary syndrome and/or coronary revascularization. After baseline measurements, patients were randomly allocated on a 1:1 ratio to receive CTR (intervention group) or center-based CR (control group). The exercise training was standard in both groups with number of sessions and intensity tailored depending on need. Other core components including psychological counseling was provided to both groups. Those allocated to the CTR intervention group received access to a web-based application and were provided with a wrist-worn heart rate monitor and a hip-worn triaxial accelerometer. The exercise training module began with six supervised group-based sessions. Exercise training was then continued at home unless the patient preferred otherwise. Weekly video consultations with the physical therapist through the web-based application were scheduled until individual goals were achieved or the program was completed and evaluated. Patients in the intervention group uploaded sensor data to the web-based application at least once per week and reviewed these data during video consultations. Weekly telemonitoring guidance was concluded after 3 months; patients were then instructed to continue using their sensors and uploading data until study completion after 12 months. For this novel extension comprising on-demand coaching, the investigator evaluated sensor data every 4 weeks until study completion and notified the patient’s physical therapist when predefined relapses occurred.


Among 300 patients (266 men [88.7%]), the mean (SD) age was 60.7 (9.5) years. The quality of life at baseline, 3 months, and 12 months among patients receiving CTR versus center-based CR was comparable during the study according to the results of two standard quality of life utility measures. Intervention costs were significantly higher for CTR (mean [SE] for all, $256 [$4] compared with center-based CR, $178 [$6]; p < 0.001); however, no difference in overall cardiac health care costs was observed between CTR ($5,467 [$574]) and center-based CR ($6,289 [$753]; p = 0.36). From a societal perspective including health care and work productivity costs, CTR was associated with lower costs compared with center-based CR, although the difference was not statistically significant ($23,405 [$3,142] vs. $27,843 [-$4,126]; p = 0.34).


The comprehensive cost-utility analysis performed in this economic evaluation found that a CTR intervention with relapse prevention was likely to be a cost-effective alternative to conventional center-based CR among patients with CAD. Together with the findings of previous economic analyses, this study’s results may be used to further support the implementation of CTR in regular practice.


The cost-benefit of using telehealth monitoring following standard CR was demonstrated at 1 year. Considering the cost-benefit of CR as with other treatments continues over time, the societal costs of telehealth extension should continue to decrease. This was the largest of several early Dutch trials, each of which found similar results. Telemedicine for CR has been relatively popular in the United States during COVID-19. There are not adequate data to draw cost/value comparisons nor to assess the value of extension of CR with telemonitoring and telemedicine.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Coronary Artery Disease, Exercise

Keywords: Accelerometry, Acute Coronary Syndrome, Cardiac Rehabilitation, Coronary Artery Disease, Cost-Benefit Analysis, Counseling, Exercise, Health Care Costs, Heart Rate, Myocardial Revascularization, Physical Therapists, Primary Prevention, Quality of Life, Secondary Prevention, Telerehabilitation

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