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Objective: To assess the cost-effectiveness of a cardiac rehabilitation (CR) program specifically designed for cardiac patients with obesity vs standard CR. Design: Cost-effectiveness analysis based on observations in a randomized controlled trial. Setting: Three regional CR centers in the Netherlands. Participants: Cardiac patients (N=201) with obesity (BMI≥30 kg/m2) referred to CR. Interventions: Participants were randomized to a CR program specifically designed for patients with obesity (OPTICARE XL; N=102) or standard CR. OPTICARE XL included aerobic and strength exercise and behavioral coaching on diet and physical activity during 12 weeks, followed by a 9-month after-care program with “booster” educational sessions. Standard CR consisted of a 6- to 12-week aerobic exercise program, supplemented with cardiovascular lifestyle education. Main Outcome Measures: An economic evaluation, with an 18-month time horizon, in terms of quality-adjusted life years (QALYs) and costs from the societal perspective was performed. Costs were reported in 2020 Euros, discounted at a 4% annual rate, and health effects were discounted at a 1.5% annual rate. Results: OPTICARE XL CR and standard CR resulted in comparable health gain per patient (0.958 vs 0.965 QALYs, respectively; P=.96). Overall, OPTICARE XL CR saved costs (-€4542) compared with the standard CR group. The direct costs for OPTICARE XL CR were higher than for standard CR (€10,712 vs €9951), whereas indirect costs were lower (€51,789 vs €57,092), but these differences were not significant. Conclusions: This economic evaluation showed no differences between OPTICARE XL CR and standard CR in health effects and costs in cardiac patients with obesity.

Background: There is an urgent need to find new approaches that improve long-term adherence to a healthy lifestyle for people with cardiovascular disease (CVD). Deposit contracts (a financial incentive in which the participant deposits own money) are inexpensive and effective, but acceptability among CVD patients is unclear. This study investigated the acceptability of a deposit contract intervention for physical activity among CVD patients. Methods: We approached CVD patients through the Harteraad patient panel of the Dutch CVD patient organization and asked them to fill in an online survey. In total (N = 659) CVD patients with a mean age of 66.2 years completed the survey. The survey assessed acceptability of deposit contracts, responses to a concrete example of a deposit contract for physical activity behavior change, and suitable moments for implementation. Results: Overall, half of the participants (45.6%) confirmed needing extra commitment to maintain lifestyle change. Yet, a small part of the sample was convinced by the idea that losing money could be motivating (18.8%) and indicated that they would be willing to deposit money themselves (13.2%). Responding to a concrete example of a deposit contract for physical activity, a quarter of the sample (26.2%) reported there was a chance they would participate. Furthermore, 27.1% of the participants found the deposit contract effective and 27.4% found it acceptable. Exploratory analyses showed that a subgroup of younger and lower educated participants responded more favorably. Opinions on when to start with a deposit contract were mixed. Conclusions: Because acceptability was generally found to be low, future research should also investigate strategies to leverage commitment principles for CVD patients without a cash deposit requirement. When deposit contracts are offered to CVD patients in practice, we recommend offering them as an optional, additional element to existing interventions that patients can opt-in

Background: There is an urgent need to find new approaches that improve long-term adherence to a healthy lifestyle for people with cardiovascular disease (CVD). Deposit contracts (a financial incentive in which the participant deposits own money) are inexpensive and effective, but acceptability among CVD patients is unclear. This study investigated the acceptability of a deposit contract intervention for physical activity among CVD patients. Methods: We approached CVD patients through the Harteraad patient panel of the Dutch CVD patient organization and asked them to fill in an online survey. In total (N = 659) CVD patients with a mean age of 66.2 years completed the survey. The survey assessed acceptability of deposit contracts, responses to a concrete example of a deposit contract for physical activity behavior change, and suitable moments for implementation. Results: Overall, half of the participants (45.6%) confirmed needing extra commitment to maintain lifestyle change. Yet, a small part of the sample was convinced by the idea that losing money could be motivating (18.8%) and indicated that they would be willing to deposit money themselves (13.2%). Responding to a concrete example of a deposit contract for physical activity, a quarter of the sample (26.2%) reported there was a chance they would participate. Furthermore, 27.1% of the participants found the deposit contract effective and 27.4% found it acceptable. Exploratory analyses showed that a subgroup of younger and lower educated participants responded more favorably. Opinions on when to start with a deposit contract were mixed. Conclusions: Because acceptability was generally found to be low, future research should also investigate strategies to leverage commitment principles for CVD patients without a cash deposit requirement. When deposit contracts are offered to CVD patients in practice, we recommend offering them as an optional, additional element to existing interventions that patients can opt-in, Applied Ergonomics and Design

Objective: To assess the cost-effectiveness of a cardiac rehabilitation (CR) program specifically designed for cardiac patients with obesity vs standard CR. Design: Cost-effectiveness analysis based on observations in a randomized controlled trial. Setting: Three regional CR centers in the Netherlands. Participants: Cardiac patients (N=201) with obesity (BMI≥30 kg/m2) referred to CR. Interventions: Participants were randomized to a CR program specifically designed for patients with obesity (OPTICARE XL; N=102) or standard CR. OPTICARE XL included aerobic and strength exercise and behavioral coaching on diet and physical activity during 12 weeks, followed by a 9-month after-care program with “booster” educational sessions. Standard CR consisted of a 6- to 12-week aerobic exercise program, supplemented with cardiovascular lifestyle education. Main Outcome Measures: An economic evaluation, with an 18-month time horizon, in terms of quality-adjusted life years (QALYs) and costs from the societal perspective was performed. Costs were reported in 2020 Euros, discounted at a 4% annual rate, and health effects were discounted at a 1.5% annual rate. Results: OPTICARE XL CR and standard CR resulted in comparable health gain per patient (0.958 vs 0.965 QALYs, respectively; P=.96). Overall, OPTICARE XL CR saved costs (-€4542) compared with the standard CR group. The direct costs for OPTICARE XL CR were higher than for standard CR (€10,712 vs €9951), whereas indirect costs were lower (€51,789 vs €57,092), but these differences were not significant. Conclusions: This economic evaluation showed no differences between OPTICARE XL CR and standard CR in health effects and costs in cardiac patients with obesity.

Background: Healthy living is key in the prevention and rehabilitation of cardiovascular disease (CVD). Yet, supporting and maintaining a healthy lifestyle is exceptionally difficult and people differ in their needs regarding optimal support for healthy lifestyle interventions. Objective: The goals of this study were threefold: to uncover stakeholders’ needs and preferences, to translate these to core values, and develop eHealth technology based on these core values. Our primary research question is: What type of eHealth application to support healthy living among people with (a high risk of) CVD would provide the greatest benefit for all stakeholders? Methods: User-centered design principles from the CeHRes roadmap for eHealth development were followed to guide the uncovering of important stakeholder values. Data were synthesized from various qualitative studies (i.e., literature studies, interviews, think-aloud sessions, focus groups) and usability tests (i.e., heuristic evaluation, cognitive walkthrough, think aloud study). We also developed an innovative application evaluation tool to perform a competitor analysis on 33 eHealth applications. Finally, to make sure to take into account all end-users needs and preferences in eHealth technology development, we created personas and a customer journey. Results: We uncovered 10 universal values to which eHealth-based initiatives to support healthy living in the context of CVD prevention and rehabilitation should adhere to (e.g., providing social support, stimulating intrinsic motivation, offering continuity of care). These values were translated to 14 desired core attributes and then prototype designs. Interestingly, we found that the primary attribute of good eHealth technology was not a single intervention principle, but rather that the technology should be in the form of a digital platform disseminating various interventions, i.e., a ‘one-stop-shop’. Conclusion: Various stakeholders in the field of cardiovascular pr

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

While the beneficial effects of secondary prevention of cardiovascular disease are undisputed, implementation remains challenging. A gap between guideline-mandated risk factor targets and clinical reality was documented as early as the 1990s. To address this issue, research groups in the Netherlands have performed several major projects. These projects address innovative, multidisciplinary strategies to improve medication adherence and to stimulate healthy lifestyles, both in the setting of cardiac rehabilitation and at dedicated outpatient clinics. The findings of these projects have led to changes in prevention and rehabilitation guidelines.

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Background: Cardiac rehabilitation (CR) is a clinically-effective but complex model of care. The purpose of this study was to characterize the nature of CR programs around the world, in relation to guideline recommendations, and compare this by World Health Organization (WHO) region. Methods: In this cross-sectional study, a piloted survey was administered online to CR programs globally. Cardiac associations and local champions facilitated program identification. Quality (benchmark of ≥ 75% of programs in a given country meeting each of 20 indicators) was ranked. Results were compared by WHO region using generalized linear mixed models. Findings: 111/203 (54.7%) countries in the world offer CR; data were collected in 93 (83.8%; N = 1082 surveys, 32.1% program response rate). The most commonly-accepted indications were: myocardial infarction (n = 832, 97.4%), percutaneous coronary intervention (n = 820, 96.1%; 0.10), and coronary artery bypass surgery (n = 817, 95.8%). Most programs were led by physicians (n = 680; 69.1%). The most common CR providers (mean = 5.9 ± 2.8/program) were: nurses (n = 816, 88.1%; low in Africa, p < 0.001), dietitians (n = 739, 80.2%), and physiotherapists (n = 733, 79.3%). The most commonly-offered core components (mean = 8.7 ± 1.9 program) were: initial assessment (n = 939, 98.8%; most commonly for hypertension, tobacco, and physical inactivity), risk factor management (n = 928, 98.2%), patient education (n = 895, 96.9%), and exercise (n = 898, 94.3%; lower in Western Pacific, p < 0.01). All regions met ≥ 16/20 quality indicators, but quality was < 75% for tobacco cessation and return-to-work counseling (lower in Americas, p ≤ 0.05). Interpretation: This first-ever survey of CR around the globe suggests CR quality is high. However, there is significant regional variation, which could impact patient outcomes.

Background: Despite the epidemic of cardiovascular disease and the benefits of cardiac rehabilitation (CR), availability is known to be insufficient, although this is not quantified. This study ascertained CR availability, volumes and its drivers, and density. Methods: A survey was administered to CR programs globally. Cardiac associations and local champions facilitated program identification. Factors associated with volumes were assessed using generalized linear mixed models, and compared by World Health Organization region. Density (i.e. annual ischemic heart disease [IHD] incidence estimate from Global Burden of Disease study divided by national CR capacity) was computed. Findings: CR was available in 111/203 (54.7%) countries; data were collected in 93 (83.8% country response; N = 1082 surveys, 32.1% program response rate). Availability by region ranged from 80.7% of countries in Europe, to 17.0% in Africa (p < 0.001). There were 5753 programs globally that could serve 1,655,083 patients/year, despite an estimated 20,279,651 incident IHD cases globally/year. Volume was significantly greater where patients were systematically referred (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.35–1.38) and programs offered alternative models (OR = 1.05, 95%CI = 1.04–1.06), and significantly lower with private (OR = 0.92, 95%CI = 0.91–0.93) or public (OR = 0.83, 95%CI = 0.82–0.84) funding compared to hybrid sources. Median capacity (i.e., number of patients a program could serve annually) was 246/program (Q25–Q75 = 150–390). The absolute density was one CR spot per 11 IHD cases in countries with CR, and 12 globally. Interpretation: CR is available in only half of countries globally. Where offered, capacity is grossly insufficient, such that most patients will not derive the benefits associated with participation.