Böckmann, D., Szentes, B. L., Schultz, K., Nowak, D., Schuler, M., Schwarzkopf, L.

Cost-effectiveness of pulmonary rehabilitation in patients with bronchial asthma: an analysis of the EPRA randomized controlled trial


Value in Health. doi: 10.1016/j.jval.2021.01.017

Zum Verlag und zum kostenpflichtigen Volltext: https://www.valueinhealthjournal.com/article/S1098-3015(21)00152-2/fulltext


  • Pulmonary rehabilitation (PR) for patients with not-well-controlled asthma is covered by Germany’s Social Insurance scheme, but the cost-effectiveness of this intervention has never been investigated in international or national studies. PR is linked to clinically relevant improvements of asthma control and disease-specific health-related quality of life that persist at least until 3 months after the intervention.
  • Three months after the end of PR, indirect costs are substantially lower in individuals who underwent PR, and direct costs tend to be lower as well. Assuming that the expected factual spending on PR is a societally accepted cost-effectiveness threshold, PR has a probability of achieving clinically relevant changes in asthma control and disease-specific health-related quality of life that is efficiently close to 100%.
  • However, despite clinically relevant changes of asthma-relevant parameters, QALY-based cost-utility analyses fail to demonstrate cost-effectiveness of PR. Therefore, purely QALY-based health policy decision making seems inappropriate to comprehensively judge the added value of PR in the field of asthma, and an additional consideration of disease-related outcome measures is highly encouraged.


Objectives At 3 months after the intervention, this study evaluates the cost-effectiveness of a 3-week inpatient pulmonary rehabilitation (PR) in patients with asthma compared with usual care alongside the single-center randomized controlled trial—Effectiveness of Pulmonary Rehabilitation in Patients With Asthma.

Methods Adopting a societal perspective, direct medical costs and productivity loss were assessed using the Questionnaire for Health-Related Resource Use-Lung, a modification of the FIM in an Elderly Population. The effect side was operationalized as minimal important differences (MIDs) of the Asthma Control Test (ACT) and the Asthma Quality of Life Questionnaire (AQLQ) and through quality-adjusted life-years (QALYs) gained. Adjusted mean differences in costs (gamma-distributed model) and each effect parameter (Gaussian-distributed model) were simultaneously calculated within 1000 bootstrap replications to determine incremental cost-effectiveness ratios (ICERs) and to subsequently delineate cost-effectiveness acceptability curves.

Results PR caused mean costs per capita of €3544. Three months after PR, we observed higher mean costs (Δ€3673; 95% confidence interval (CI) €2854-€4783) and improved mean effects (ACT Δ 1.59 MIDs, 95% CI 1.37-1.81; AQLQ Δ1.76 MIDs, 95% CI 1.46-2.08; QALYs gained Δ0.01, 95% CI 0.01-0.02) in the intervention group. The ICER was €2278 (95% CI €1653-€3181) per ACT-MID, €1983 (95% CI €1430-€2830) per AQLQ-MID, and €312 401 (95% CI €209 206-€504 562) per QALY gained.

Conclusions Contrasting of PR expenditures with ICERs suggests that the intervention, which achieves clinically relevant changes in asthma-relevant parameters, has a high probability to be already cost-effective in the short term. However, in terms of QALYs, extended follow-up periods are likely required to comprehensively judge the added value of a one-time initial investment in PR.


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