Skip to main content

Strategies for cost-effectiveness analysis of rehabilitation for older patients with acute heart failure


The prevalence of heart failure (HF) is increasing in the ageing world population, and its burden on the medical and health economic fields is enormous. Rehabilitation is an essential component of the nonpharmacological treatment of patients with HF; however, its efficacy and cost-effectiveness for patients with acute HF remain unclear. A trial assessed the cost-effectiveness of acute cardiac rehabilitation among older adults. Herein, we discussed strategies for the cost-effectiveness analysis of acute cardiac rehabilitation using the rehabilitation therapy in older acute heart failure patients trial.


Heart failure (HF) is a major public health issue, and its global burden on the medical and health economic sectors is enormous. The annual healthcare budget for HF is high, accounting for 1–2% of the total annual healthcare budget in Europe and the United States (US). In addition, the total health expenditure for HF in the US is expected to increase by 127% between 2012 and 2030 [1]. The incidence rate of HF has decreased in the last decades; however, its prevalence is increasing due to advancements in HF treatment methods and longer life-expectancy of HF patients [2]. Thus, it is important to focus on people living with HF. The key population in HF patients is older adults, in whom the most frequent cause of hospitalization is HF. In addition, 80% of hospitalizations and 90% of deaths in HF patients occur among older adults [3]. Due to the increase in the global ageing population and the increasing prevalence of HF, the burden of HF is expected to increase.

Exercise-based rehabilitation is a nonpharmacological method of HF treatment. A clinical guideline has reported that cardiac rehabilitation is useful for clinically stable patients with HF [4]. In contrast, due to the global lack of evidence of the benefits of cardiac rehabilitation in acute HF patients, rehabilitation in them is not common. In reality, the public health insurance policies of Medicare and Medicaid do not cover rehabilitation services for acute HF patients.

One important clinical trial involving older acute HF patients was conducted in the U.S., and subsequently the cost-effectiveness analysis (CEA) was published [5]. CEA is an important aspect for policy makers who are working with public health insurance systems. The study found that when rehabilitation intervention was compared with no-rehabilitation, the Incremental Cost-Effectiveness Ratio (ICER) of the rehabilitation was $58 409 per Quality Adjusted Life years (QALY). In the probabilistic sensitivity analysis, 45% and 54% of simulated ICERs were at or below the conventionally accepted thresholds of $50,000 and $100,000, respectively in the overall study participants including those with HF with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF). In contrast, improvements in outcomes were greater, and the cost-effectiveness was more in patients with HFpEF than in those with HFrEF. We would like to discuss four points based on the CEA using the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial. The points discussed arose based on the Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) checklist and were summarized in Table 1 [6].

Table 1 Summary of our comments on the CEA of acute cardiac rehabilitation and the corresponding items on the Consolidated Health Economic Evaluation Reporting Standards checklist 2022

Study population

The first point is the patient population in the trial. The REHAB-HF trial included approximately 55% of frail older adults, but excluded approximately 98% of patients with acute HF due to the following reasons: dementia, dependent on activities of daily living, planned discharge to a nursing home, and difficulties complying with trial requirements [7]. This could have contributed to the lack of generalizability of the results of the trial and led to the inaccurate evaluation of the cost-effectiveness of rehabilitation for acute HF patients. One of the evidence issues of randomized controlled trials on HF is that most of them exclude the oldest patients, whose need for treatment and care is increasing [8]. The mean age ± standard deviation was 72.7 ± 8.1 years in the REHAB-HF trial, and this implies that the oldest patients were excluded for reasons such as being dependent and having dementia. In CEAs for public health insurance systems, the proportion of patients with a particular characteristic such as the disease type and age is needed to be considered. In addition, the food and drug administration has issued guidance to enhance diversity in clinical trials and recommends including people with disability [9]. In future CEAs for acute cardiac rehabilitation, those who were excluded in the REHAB-HF trial should be considered.


The second point is the comparator in the trial. According to the 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure, it is recommended that such patients in the REHAB-HF trial should receive care from multidisciplinary teams as a nonpharmacological intervention [10]. To ensure external validity, a comparator should represent best or common practice [11]. Thus, the comparator should be care from multidisciplinary teams in the future CEAs for acute cardiac rehabilitation.


The third point is the cost related to caregiver burden. Both the patients and their caregivers should be considered in CEAs of trials including older adults who need some assistance in their activities of daily life. The Second Panel on Cost-effectiveness in Health and Medicine recommends using not only payer’s perspective, but also societal perspective, which considers the effect of the intervention on the patients, caregivers, and social resources in a CEA with a long-time horizon [12]. Caregiver burden in HF is a significant issue and can influence the health outcomes of both the patients and their caregivers [13]. Including the indirect costs such as the health status of caregivers and their lost opportunity and lost productivity costs in a CEA may be useful during an appraisal by policy makers.


Finally, there are two issues in the modelling for CEA. The time horizon used in the CEA of the REHAB-HF trial was lifetime. The time horizon must be long enough that the intended and unintended benefits and harms are captured [14]. In contrast, using a time horizon that is longer than necessary could add unnecessary cost, and interpreting the cost-effectiveness might become too difficult [14]. According to the CHEERS 2022 statement, giving reasons for setting a time horizon for a certain period is one of the domains [6]. In general, it is unlikely that the effects of rehabilitation in the acute phase of HF last throughout life, although the author of the article also mentioned that there is uncertainty in the duration of the effect of intervention [5]. In that case, using the available evidence from observational studies and expert opinions or referring to trials examining the duration of the effect of a similar intervention may be useful in setting the time horizon in a CEA. Moreover, conducting scenario analyses using some time horizons might help policy makers in making their decision. The second point is that the lifetime cost and QALY were estimated using a model that was developed and validated by trials involving patients with chronic HF who did not undergo acute cardiac rehabilitation [15]. Thus, modelling using the data of patients who underwent acute cardiac rehabilitation, e.g., data from a clinical trial with long-follow up or real-world data, can lead to a more accurate estimation of the cost-effectiveness.


We discussed the strategy for the CEA of acute cardiac rehabilitation in older adults with HF using the REHAB-HF trial. Considering more frail older people (who can be a key population in HF in the ageing world) and the cost related to caregiver burden, and modelling with an appropriate time horizon and more accurate data may be useful in the future analysis of the cost-effectiveness of acute cardiac rehabilitation in older adults.

Availability of data and materials

Not applicable.



Cost-effectiveness analysis


Consolidated Health Economic Evaluation Reporting Standards


Heart failure


Incremental cost-effectiveness ratio


Quality Adjusted Life years


Rehabilitation Therapy in Older Acute Heart Failure Patients


  1. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, et al. Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation. 2016;133:e38-60.

    PubMed  Google Scholar 

  2. Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats A. Global burden of heart failure: A comprehensive and updated review of epidemiology. Cardiovasc Res. 2022;23:013.

    Google Scholar 

  3. Liao L, Allen LA, Whellan DJ. Economic burden of heart failure in the elderly. PharmacoEconomics. 2008;26:447–62.

    Article  Google Scholar 

  4. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128:e240-327.

    PubMed  Google Scholar 

  5. Chew DS, Li Y, Zeitouni M, Whellan DJ, Kitzman D, Mentz RJ, Duncan P, Pastva AM, Reeves GR, Nelson MB, et al. Economic Outcomes of Rehabilitation Therapy in Older Patients With Acute Heart Failure in the REHAB-HF Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol. 2022;7(2):140–8.

    Article  Google Scholar 

  6. Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, Caulley L, Chaiyakunapruk N, Greenberg D, Loder E, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 Explanation and Elaboration: A Report of the ISPOR CHEERS II Good Practices Task Force. Value Health. 2022;25:10–31.

    Article  Google Scholar 

  7. Kitzman DW, Whellan DJ, Duncan P, Pastva AM, Mentz RJ, Reeves GR, Nelson MB, Chen H, Upadhya B, Reed SD, et al. Physical rehabilitation for older patients hospitalized for heart failure. N Engl J Med. 2021;385:203–16.

    Article  Google Scholar 

  8. Zannad F. Rising incidence of heart failure demands action. Lancet. 2018;391:518–9.

    Article  Google Scholar 

  9. Enhancing the Diversity of Clinical Trial Populations — Eligibility Criteria, Enrollment Practices, and Trial Designs Guidance for Industry [] Acessed 1 Mar 2022.

  10. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895-1032.

    PubMed  Google Scholar 

  11. Ramsey SD, Willke RJ, Glick H, Reed SD, Augustovski F, Jonsson B, Briggs A, Sullivan SD. Cost-effectiveness analysis alongside clinical trials II-An ISPOR Good Research Practices Task Force report. Value Health. 2015;18:161–72.

    Article  Google Scholar 

  12. Sanders GD, Neumann PJ, Basu A, Brock DW, Feeny D, Krahn M, Kuntz KM, Meltzer DO, Owens DK, Prosser LA, et al. Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses: Second Panel on Cost-Effectiveness in Health and Medicine. JAMA. 2016;316:1093–103.

    Article  Google Scholar 

  13. Nicholas Dionne-Odom J, Hooker SA, Bekelman D, Ejem D, McGhan G, Kitko L, Strömberg A, Wells R, Astin M, Metin ZG, et al. Family caregiving for persons with heart failure at the intersection of heart failure and palliative care: a state-of-the-science review. Heart Fail Rev. 2017;22:543–57.

    Article  CAS  Google Scholar 

  14. Basu A, Maciejewski ML. Choosing a time horizon in cost and cost-effectiveness analyses. JAMA. 2019;321:1096–7.

    Article  Google Scholar 

  15. Reed SD, Neilson MP, Gardner M, Li Y, Briggs AH, Polsky DE, Graham FL, Bowers MT, Paul SC, Granger BB, et al. Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model: A Web-based program designed to evaluate the cost-effectiveness of disease management programs in heart failure. Am Heart J. 2015;170:951–60.

    Article  Google Scholar 

Download references


KS receives support from Japan Society for the Promotion of Science KAKENHI (Grant Number 21K21051).

Author information

Authors and Affiliations



Conceptualization: KS Supervision: EH and RM Writing: KS. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kotomi Sakai.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

No competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sakai, K., Momosaki, R. & Hoshino, E. Strategies for cost-effectiveness analysis of rehabilitation for older patients with acute heart failure. Cost Eff Resour Alloc 20, 53 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Rehabilitation
  • Older adults
  • Cost-effectiveness analysis