Cost-Effectiveness of Case Management and Financial Incentives to Increase Participation in Cardiac Rehabilitation

Donald S Shepard; Jiaye Shen; Blair K Yant; Deborah E Denkmann; Patrick D Savage; Robin K Collier; Brian R Katz; Philip A Ades; Diann E Gaalema

doi:10.1097/HCR.0000000000000952

Cost-Effectiveness of Case Management and Financial Incentives to Increase Participation in Cardiac Rehabilitation

J Cardiopulm Rehabil Prev. 2025 Jul 1;45(4):278-285. doi: 10.1097/HCR.0000000000000952. Epub 2025 May 20.

Authors

Donald S Shepard¹, Jiaye Shen, Blair K Yant, Deborah E Denkmann, Patrick D Savage, Robin K Collier, Brian R Katz, Philip A Ades, Diann E Gaalema

Affiliation

¹ Author Affiliations: Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts (Drs Shepard and Shen); Larner College of Medicine, University of Vermont, Burlington, Vermont (Ms Yant, Ms Denkmann, Ms Collier, Dr Katz, and Dr Gaalema); Cardiac Rehabilitation Program, University of Vermont Medical Center, Burlington, Vermont (Mr Savage and Dr Ades); and Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas (Drs Katz and Gaalema).

PMID: 40388221
DOI: 10.1097/HCR.0000000000000952

Abstract

Purpose: 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).

Methods: 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.

Results: 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).

Conclusions: 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.

Keywords: cardiac rehabilitation; case management; coronary heart disease; cost-effectiveness; incentives.

Publication types

Randomized Controlled Trial

MeSH terms

Aged
Cardiac Rehabilitation* / economics
Cardiac Rehabilitation* / methods
Case Management* / economics
Cost-Benefit Analysis
Female
Humans
Male
Medicare / economics
Motivation*
Patient Participation*
Quality-Adjusted Life Years
United States