Cardiovascular diseases are the number one cause of mortality in most industrially developed countries. In Europe, about 4 million people die annually from cardiovascular disease. In a group of people under 65, cardiovascular disease has a 31% mortality rate for men and 26% for women. For the southern states, particularly France and Spain, long-term low cardiovascular mortality rates are typical. This fact is associated with the so-called nutritional paradox (French paradox), which is a contradiction between not so healthy eating and low cardiovascular mortality. It is believed that this phenomenon is related to the positive influence of the Mediterranean diet and lifestyle. In the Czech Republic, cardiovascular disease contributed to total mortality with 43% in 2014 [1].
Treatment of people with cardiovascular disease is divided into pharmacological and non-pharmacological. Non-pharmacological treatment includes invasive procedures and cardiovascular rehabilitation. Despite the great merit of acute surgery, due to modern technology and advances in medicine consideration should be given to preventing recurrence or progression of the disease. This is where cardiovascular rehabilitation and physical activity come to the picture. It is a very effective and when following the guidelines also a safe tool to positively affect the risk factors such as overweight, hypertension, dyslipidaemia or insulin resistance. Unfortunately, CV RHB and physical activity are still largely under-represented among the Czech population [26]. Physical activity is an integral part of cardiovascular rehabilitation. Into this area, we also include education about healthy lifestyle and the associated elimination of possible risk factors, especially smoking cessation programs, nutritional counselling and psychological counselling. A Canadian study dealing with the state of cardiovascular rehabilitation services conducted a research in 40 countries where CV RHB services were provided in 26 of them, and in most of them, the rehabilitation program consisted of physical exercise, nutrition counselling, psychological counselling and anti-smoking programs [27].
In the Czech Republic, a spa treatment which is well-accessible from a demographic point of view is still a great tradition. However, from 2010 to 2016, there was a significant decrease in the number of patients, by 64%. In 2016, therefore, a total of 4885 adults with a circulatory disorder received a spa treatment at the cost of a health insurance company. According to the published statistics [28], this trend can be caused by both a change in the health care reimbursements system from the side of the health insurers and an attempt to return to working life as soon as possible.
Another option for performing cardiovascular rehabilitation is outpatient treatment. There aren’t many facilities that provide this type of service comparing to spas. The reason may be, among other things, costly and complex devices equipment that is required to operate such service, the already mentioned need for comprehensive care including movement component, dietary measures and psychological counselling and the necessary training of health professionals in order to provide specialized rehabilitation care [29].
The difference in the perception of these two types of cardiac rehabilitation is in a sense quite substantial and it needs to be mentioned. The spa treatment of the circulatory system as well as the spa treatment in general is perceived by the patient as a specific one-time type of recreation where the patient finds himself in a different environment outside the working process, surrounded by people with similar difficulties, and his stay has a regimen of clearly defined, scheduled procedures. This kind of treatment usually has a very positive impact on the patient and the treatment effect can last for several months. After completing the treatment and returning to a “normal” life, however, it often happens that people slowly return back into their old habits they used to have before the treatment and their lifestyle is once again moving towards a negative direction. For cardiac patients, this can mean a return to poor dietary habits, physical inactivity or stress. And these factors, despite the patient’s motivation to continue a healthy lifestyle even outside the spa, can lead to a worsening of the disease. Outpatient rehabilitation treatment is perceived by the patient as a necessity to “go somewhere” twice a week. During the treatments, the patient finds himself in his common professional and personal circumstances and in a relatively short time it should encourage him or her to actively cooperate and change his/her lifestyle. It is not an unusual phenomenon that a patient who is at first apathetic and inactive is experiencing much more enthusiasm after a few weeks of exercise than during the first visit. Therefore, the patient is encouraged during ambulatory and spa cardio rehabilitation to make this treatment not just a one-time matter but a part of his lifestyle. As found from the study, the most significant difference between these two types of treatments were reflected in the duration of positive effect after the treatment determined by the cardiologists of the facilities. While the more intense spa treatment was rated with a lasting effect of 9 months, the duration of the effect of outpatient treatment after attending 20 sessions was 3 months. It should be emphasized that ambulatory CV RHB achieves the greatest effects after 2 years of treatment. A meta-analysis of 63 randomized trials involving a total of 21,295 patients was performed by Clark AM et al. [30]. The study shows that the 12-month CV RHB reduces the recurrence of myocardial infarction by 17%. After 2 years of rehabilitation, mortality is reduced by 47%.
In the questionnaire survey framework, the aim was to carry out a research in patients (cardiac patients) without focusing on a specific diagnosis. This decision was made because of how time-consuming data collection is and in order to get more respondents in case of one diagnosis. The suitability of a selected sample of patients was consulted with a cardiologist. The programs of both therapeutic interventions were identical for all patients in the groups. The groups were divided according to CV RHB phase into a group of patients undergoing early spa rehabilitation treatment and two groups of patients undergoing spa and outpatient rehabilitation care at a later stage of CV RHB. Groups equal and thus relevantly comparable are the last two groups mentioned, as evidenced by similar values of the Index value (0.726 and 0.747) of the EQ-5D-5L questionnaires at the start of treatment. A group of early rehabilitation patients are mentally and physically unstable, and in the questionnaire survey, the Index value is significantly lower (0.710) before treatment. Therefore, it cannot be considered as an equivalent comparator to other groups, but due to the existence of data, it was ranked and processed for comparison. The results of the questionnaire survey show that at a later stage, CV RHB achieved greater improvement, i.e. a greater difference in the Index value of outpatient treatment patients. The resulting QALY value is higher for spa patients due to the higher duration of the effect.
Effect values, especially effects of late spa treatment, most influenced the ICUR value in the sensitivity analysis. In particular, Konstantin Spa Index value difference and the Effect duration Konstantin Spa had a significant impact on ICUR and decision about cost-effectiveness of the treatment. In another words, effect of late spa treatment must be 1.5 times longer than effect of Cardio ambulance.
Based on the results of the study, recommendations for cardiovascular rehabilitation can be established. The cardiac rehabilitation of cardiac patients at the early stage of CV RHB had the greatest clinical effect. Therefore, we can cautiously say that this type of treatment has its place in cardiovascular rehabilitation and, based on the experience of the spa, there is a marked improvement in the physical and mental health of the patient. To confirm cost effectiveness, we would need to create another study that would have a suitable comparator which the other two groups did not meet in this study. The results of the main two groups of patients at the later stage of CV RHB have shown better cost-effectiveness ration (C/U) in outpatient cardiovascular rehabilitation. Outpatient treatment is therefore a suitable alternative to spa treatment at a given stage of rehabilitation, especially in productive patients, in terms of saving the cost of lost earnings from employment. Due to the increasing prevalence of chronic forms of cardiovascular disease, the late rehabilitation phase is very relevant. However, it is not only necessary to increase the availability of given rehabilitation care but also to improve the awareness of the possibilities of cardiovascular rehabilitation, not only among patients but also among professionals (physicians). These were one of the reasons why we decided to carry out this study [31].