Mohebbi D, et al. BMJ Open Sp Ex Med 2024;10:e001896. doi:10.1136/bmjsem-2024-001896 1 Open access Original research Cost-effectiveness of incentives for physical activity in coronary heart disease in Germany: pre-trial health economic model of a complex intervention following the new MRC framework Damon Mohebbi , 1,2 Katherine Ogurtsova, 3 Jan Dyczmons, 2 Markos Dintsios, 1 Nadja Kairies-Schwarz, 1 Christian Jung, 4,5 Andrea Icks 1,2 To cite: Mohebbi D, Ogurtsova K, Dyczmons J, et al. Cost-effectiveness of incentives for physical activity in coronary heart disease in Germany: pre- trial health economic model of a complex intervention following the new MRC framework. BMJ Open Sport & Exercise Medicine 2024;10:e001896. doi:10.1136/ bmjsem-2024-001896 ► Additional supplemental material is published online only. To view, please visit the journal online (https://doi. org/10.1136/bmjsem-2024- 001896). Accepted 22 April 2024 For numbered affiliations see end of article. Correspondence to Mr Damon Mohebbi; Damon.Mohebbi@hhu.de © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. ABSTRACT Objectives The German Incentives for Physical Activity in Cardiac Patients trial is a three-arm, randomised controlled trial for secondary prevention of coronary heart disease (CHD). Guidance for developing complex interventions recommends pre-trial health economic modelling. The aim of this study is to model the long-term cost-effectiveness of the incentive-based physical activity interventions in a population with CHD. Methods A decision-analytical Markov model was developed from a health services provider perspective, following a cohort aged 65 years with a previous myocardial infarction for 25 years. Monetary and social incentives were compared relative to no incentive. Intervention effects associated with physical activity were used to determine the costs, quality-adjusted life-years (QALYs) gained, incremental cost-effectiveness and cost–utility ratios. The probability of cost-effectiveness was calculated through sensitivity analyses. Results The incremental QALYs gained from the monetary and social incentives, relative to control, were respectively estimated at 0.01 (95% CI 0.00 to 0.01) and 0.04 (95% CI 0.02 to 0.05). Implementation of the monetary and social incentive interventions increased the costs by €874 (95% CI €744 to €1047) and €909 (95% CI €537 to €1625). Incremental cost–utility ratios were €25 912 (95% CI €15 056 to €50 210) and €118 958 (95% CI €82 930 to €196 121) per QALY gained for the social and monetary incentive intervention, respectively. With a willingness-to-pay threshold set at €43 000/QALY, equivalent to the per-capita gross domestic product in Germany, the probability that the social and monetary incentive intervention would be seen as cost- effective was 95% and 0%, respectively. Conclusions Exercise-based secondary prevention using inventive schemes may offer a cost-effective strategy to reduce the burden of CHD. INTRODUCTION Cardiovascular diseases (CVDs) continue to be the leading cause of disease burden in the world. 1 Coronary heart disease (CHD) is the predominant type of CVD which affected 197 million people in 2019. 1 In Germany, although mortality rates have declined, high prevalence persists. 2 With over €46 billion, CVDs cause the highest costs to the German healthcare system compared with all other disease groups. 3 Secondary prevention of CHD can improve life quality, reduce cardiovascular events and mortality. 4 However, inadequate imple- mentation and low participation persist. 5 Physical activity (PA) is crucial in secondary prevention, 6 7 but implementing exercise recommendations remains problematic. 8 Both financial and non-financial incentives have been proposed to act as external stimuli and can foster engagement in PA programmes. Their design can influence intervention effec- tiveness, costs and cost-effectiveness. Reviews show partly mixed results but suggest positive WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ Incentives can serve as external stimuli, modifying physical activity behaviours, but their long-term cost-effectiveness among adults with coronary heart disease remains unexplored to date. WHAT THIS STUDY ADDS ⇒ Incentive schemes for physical activity in the sec- ondary prevention of coronary heart disease may lead to cost-effectiveness but not to cost savings. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY ⇒ Pre-trial modelling is a comprehensive health eco- nomic tool to inform complex interventions. ⇒ Investment in incentivised physical activity interven- tions may provide good value for money. copyright. on July 25, 2024 by guest. Protected by http://bmjopensem.bmj.com/ BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2024-001896 on 27 May 2024. Downloaded from