Incentives for physical activity in cardiac patients in Germany: pre-trial health economic modelling

Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Düsseldorf Cardiovascular disease (CVD) is the most prevalent non-communicable disease and the leading cause of death globally. Evidence suggests that exercise-based interventions in secondary prevention can mitigate adverse health events. Implementing incentive schemes for patients to engage in physical activity (PA) might be a promising approach to improve adherence. The INPHY trial, a complex intervention that is currently being developed at the University Hospital Düsseldorf, aims at improving PA in people with coronary heart disease (CHD) using monetary and social incentives. The UK Medical Research Council (MRC) framework for the development and evaluation of complex interventions recommends pre-trial health economic modelling to inform the design of the trial. A decision-analytic Markov model was developed to evaluate the costs and benefits of exercise-based, incentivized secondary prevention interventions from a health services provider. A cohort of individuals with a history of myocardial infarction was followed in the model from age 65 years through a total of 25 1-year Markov cycles. Primary outcomes included costs, quality-adjusted life-years (QALY) gained and incremental cost-effectiveness ratios (ICERs). Sensitivity and scenario analyses were performed to reflect parameter and model uncertainty. In the base-case, the incremental QALYs gained from the monetary and social incentives, relative to control, were respectively estimated at 0.01 [95% CI 0.00-0.01] and 0.03 [95% CI 0.02-0.05]. In comparison to control, the implementation of the monetary and social incentive interventions increased the costs by 795€ [95% CI 697-884] and 831€ [95% CI 593-1,191], respectively. ICERs were 24,473€ [95% CI 15,871-38,868] and 112,015€ [95% CI 81,140-169,888] per QALY gained for the social and monetary incentive interventions, respectively. At a per-capita gross domestic product threshold (GDP) of 43,000€/QALY for Germany, the probability that the social and monetary incentive intervention would be seen as cost effective was 100% and 0%, respectively. Exercise-based secondary prevention using incentivized reinforcement schemes might offer a cost-effective strategy to reduce the burden of CHD, offering good value for money in preventing a significant non-communicable disease. Translation of these findings into policy and practice alongside rigorous monitoring and evaluation is important. More epidemiological research from Germany is recommended to reduce the remaining model uncertainty surrounding this decision.