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Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health (2010)

Chapter: 7 Making Choices to Reduce the Burden of Cardiovascular Disease

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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

7
Making Choices to Reduce the Burden of Cardiovascular Disease

It is clear from preceding chapters that the health and economic burden of cardiovascular disease (CVD) is high. This burden is likely to rise and remain unacceptably high in developing countries unless bold moves are made to implement policies and programs to contain the growth in prevalence of CVD and other chronic diseases, to develop and implement affordable and accessible health services and technology, and to reduce the financial risks to individuals and economies.

Aggressively reducing population and individual CVD risks would not only help low and middle income countries avert a potential crisis by reducing their chronic disease burden, it could also be viewed as an opportunity to improve both their economies and their public health. However, many developing countries face a difficult challenge: to make further headway against infectious diseases and other health concerns where they remain rampant while transforming health systems to accomplish chronic disease prevention and care. Very limited resources are available for health in developing countries, and there are great gaps in meeting needs. Therefore, the strategy in developing countries should be to seek low-cost approaches with a high potential return on investment to achieve structural and behavioral changes to reduce risk, and low-cost technology and health delivery to effectively treat and manage CVD.

There is a particular urgency to the need to identify and implement those interventions that can reap the biggest CVD reduction benefits in low and middle income countries while at the same time offering good “value for money.” Many of these countries are confronting a mounting gap between the dual disease burden they experience and the ability of

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

their health systems to deliver adequate care. Other countries are making headway as they and/or donors increase resource allocations to health. In both instances, informed choices about what the available resources will buy can better align needed and realized health improvements.

ECONOMIC INFORMATION TO HELP ALLOCATE RESOURCES

Economic measurements and analysis are critically important to inform decisions both about allocating resources and choosing among alternative solutions to the problem within and beyond the health sector. The health economics literature relies almost exclusively on cost-effectiveness measures to assess value for money. Cost-effectiveness analysis of interventions can be an important tool for choosing among interventions targeted to the same outcomes, and the first section of this chapter summarizes the available cost-effectiveness evidence for CVD interventions in low and middle income countries. However, cost-effectiveness provides little information about the affordability of given interventions or the actual value to the beneficiaries, and it does not allow for ready comparisons of interventions across different sectors and different health and development priorities. The potential return on investment needs to be assessed within a broad socioeconomic context, and guidance derived from cost-effectiveness analysis may be superseded by broader policy choices for allocating resources across competing priorities within the parameters that society sets for achieving better health and well-being. Economic benefit–cost analysis can be used to balance tradeoffs in choosing among alternatives, such as new technologies or investments in structural and policy changes. However, the analytical and data demands are much higher, and there are almost no cost–benefit studies available from developing countries on CVD interventions. Ultimately, decisions about how to prioritize investments will necessitate carefully defining feasible options for change and determining the willingness of stakeholders to shift resources to implement those changes.

Summary of Cost-Effectiveness Evidence1

The preceding chapters have provided a thorough summary of the relevant CVD interventions under consideration in low and middle income countries. This section discusses the available evidence on their cost-effectiveness, drawing primarily on two rapid reviews commissioned for this report, which built on and updated major recent efforts such as the Disease Control Priorities Project (DCP2) (Musgrove and Fox-Rushby, 2006) and the WHO initia-

1

This section is based in part on papers written for the committee by Marc Suhrcke et al. and by Stephen Jan and Alison Hayes.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

tive on Choosing Interventions That are Cost-effective (CHOICE) (WHO, 2010).2 While there is a large body of evidence on the cost-effectiveness of CVD-related interventions in developed countries, this chapter considers only evidence with an explicit focus on low and middle income countries.

Most of the available studies identified in the commissioned reviews were focused on clinical prevention strategies and case management for individuals, with far fewer studies on population-based prevention approaches. Overall, most studies in both of these categories focused on risk-factor reduction.

About half the economic studies relied on modeling analysis using estimated cost assumptions and secondary data for intervention effectiveness and epidemiological conditions rather than on primary empirical data on costs and effectiveness from observational trials or randomized controlled trials in the setting of interest. In these models, developing-country data was the source for most of the epidemiological data, but developed countries were the source of data for intervention effectiveness. The advantages and limitations of these secondary versus primary analyses will be discussed further in the final section of this chapter on future research needs.

It is also important to note that cost-effectiveness studies are difficult to compare because the threshold of what is considered cost-effective varies (the standard is 3× the per capita gross domestic product [GDP] for the country, but 1× GDP is sometimes used). In addition, the outcome measures and comparator are often not the same across studies (the standard comparator is either no intervention or current standard care in the country). Different approaches for economic evaluation are also used, as well as different measures to express cost-effectiveness (the standard is an incremental cost-effectiveness ratio [ICER] reporting the cost per averted disability-adjusted life year [DALY] or quality-adjusted life year [QALY], but an average cost-effectiveness ratio [CER] is also used).

Cost-Effectiveness of Population-Based and Other Lifestyle Interventions

Population-based and other public health interventions typically target nutrition, physical activity, and tobacco risk-factor reduction. There has been remarkably little research on non-clinical, population-based approaches, such as legislative actions, education campaigns, or health promotion through social marketing, as a way to tackle CVD in developing

2

Searches were conducted using the PubMed and EconLit databases. In addition, the references of retrieved articles and the relevant publications of the DCP2 and the WHO CHOICE program were hand-searched for relevant articles. The search strategy consisted of freetext and MeSH terms related to economic evaluation and CVD disease or risk factors endpoints, filtered for the occurrence of the term “developing countries” or any country name defined as middle or low income country according to the World Bank definition. Only published full economic evaluations were included.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

countries. Changes in health policy are beginning to be observed in developed countries such as the United Kingdom, Finland, and the United States. New strategies are being implemented, such as legislation for salt reduction and labeling of food (Karppanen and Mervaala, 2006), and some analysis has been done about the potential revenue and dietary benefits of taxes on sugared drinks and junk food (Brownell and Frieden, 2009) as well as the potential cost-effectiveness of community-based physical activity programs in the United States (Roux et al., 2008).

However, most of these strategies have yet to be implemented with a rigorous economic evaluation component. In addition, since interventions targeted to change health behaviors are highly dependent on political, cultural, infrastructural, and other system-related aspects, it is deemed less feasible to assume effectiveness results from studies in developed regions can be applied to developing regions than is commonly accepted for clinical effectiveness evidence (Jamison et al., 2006). In pharmaceutical research, for example, a common assumption is that a drug affecting biomedical processes would have approximately identical effects, irrespective of the context in which it is applied. This is less likely to be the case for a health communication campaign or for legislative or regulatory approaches.

Nonetheless, evidence from both modeling and some primary economic analysis is building that population-level interventions targeted to reduce CVD are likely to be cost-effective in low and middle income countries. Table 7.5a at the end of this chapter summarizes the cost-effectiveness results for population-based CVD interventions in a developing-country setting.

The antitobacco regulatory interventions, such as taxation, smoke-free public places, restrictions on marketing, and youth cessation are strongly supported. In particular, taxation and legislation options have been relatively well evaluated, certainly for developed regions and countries but also for developing-country settings (Chisholm et al., 2006). Those include reviews such as an article by Shibuya et al. (2003) and the Disease Control Priorities in Developing Countries publication (Jha et al., 2006), both of which describe an increase in tobacco tax as the most cost-effective strategy to reduce smoking prevalence, followed by comprehensive advertisement campaigns and bans on smoking in public places. Tobacco taxes combined with smoking and advertising bans is also cost-effective (Gaziano, 2008; Lai et al., 2007). A modeling study also showed cost savings from a community-based pharmacist-driven education and counseling program for prevention of CVD risk from smoking among high-risk groups of men and women in Thailand (Thavorn and Chaiyakunapruk, 2008).

A number of studies have found food regulation (including regulation of salt or substitution of transfats) to be highly cost-effective, even cost-saving. These studies included cooperation among government, industry, and consumer organizations to reduce the salt content in bread in Argentina

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

(Rubinstein et al., 2009) and salt reduction in processed foods through industry agreements or legislation in South-East Asia, Latin America, and Sub-Saharan Africa (Gaziano, 2008; Murray et al., 2003). However, the few studies of this type that exist have not conducted a thorough examination of the true costs of achieving policy or regulatory change, which can be high during the policy advocacy phase and then generally diminish.

Promoting physical activity is a CVD prevention intervention that has been largely overlooked by economic evaluation. The Agita São Paulo program, described in Chapter 5, is known globally as an effective intervention to promote physical activity in Brazil. It was evaluated by the World Bank and also found to be cost-effective (Matsudo et al., 2006). In a more narrow approach, a randomized controlled trial of home-based physical activity education for rehabilitation of post-MI coronary patients in Brazil showed significant improvements in all domains at a low cost (Salvetti et al., 2008).

Educational campaigns for outcomes beyond tobacco use are also shown as highly cost-effective in the few studies of this type (mainly addressing high blood pressure, high cholesterol, and lowering body mass index [BMI]), and some are even cost-saving. Cost-effectiveness modeling of health education programs for multi-risk reduction in multiple regions demonstrated positive results (Murray et al., 2003). Salt reduction through communication and mass media programs were deemed likely to be cost-effective, as well as similar programs for tobacco control, in a range of low and middle income countries at about $0.40 per person per day (Asaria et al., 2007). A population-based social marketing study with experimental and control groups in Thailand shows effective hypertension risk reduction at very low cost when village health workers were mobilized with trained health workers (Getpreechaswas et al., 2007). Bi-weekly home counseling visits by a trained health professional in Mexico were also very cost-effective in reducing hypertension (García-Peña et al., 2002). A community-based primary prevention program in Beijing to alter food intake also showed cost savings (Huang et al., 2001). However, the reported ICERs for health education interventions were quite variable. This suggests a degree of variation and uncertainty in the parameters used for such studies. It is also difficult to judge the effects of mass education programs due to difficulties in assessing numbers of persons reached.

In summary, legislated reductions in salt and transfats in foods, tobacco taxation and restrictions, and health education campaigns all show some promising cost-effectiveness across a range of countries. However, except for antitobacco measures in developed countries, the cost-effectiveness of population-based interventions has been measured almost entirely through modeling techniques. These few studies are generally supportive of one another, but need confirmation from a broad range of empirical examples using primary data.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×
Cost-Effectiveness of Pharmaceutical and Other Clinical Interventions

Cost-effectiveness results for pharmaceutical and other clinical interventions for CVD in a developing-country setting are summarized in Table 7.5b at the end of this chapter. These strategies have been the predominant focus of economic analysis to date. In summary, the cost-effectiveness of pharmaceutical interventions to reduce CVD depends heavily on the risk group targeted. Prevention with pharmacological treatment for high-risk individuals is likely to be cost-effective across a range of country settings. Prevention with pharmacological treatment is not generally likely to be cost-effective for reducing risk factors in individuals without high absolute risk.

In conclusion, just as with the available intervention effectiveness reviewed in Chapter 5, there are limitations on the available economic analyses. These limitations guide future needs, which will be discussed later in this chapter. However, they do not preclude intervening now, and some determinations can be made about priorities for investment in intervention approaches. Indeed, both intervention and economic evidence support selected population-based interventions and pharmacological interventions for high-risk target groups to reduce CVD and hypertension. Although there are interventions that are likely to be cost-effective, it remains difficult to make comparisons to draw definitive conclusions about which interventions are the most cost-effective. This is both due to the challenges of making comparisons across the available studies and due to gaps in the economic evaluation literature in some important areas of intervention that have promise for effective impact on health outcomes.

Economic Information to Compare Prevention and Treatment Strategies

When comparing interventions to reduce the burden of CVD, it is tempting to try to look to the economic analysis to make a determination about whether it would be more advisable to invest in prevention strategies or treatment strategies. To many, prevention seems like the most promising investment because of its potential for avoidance of costly treatment interventions (technology, hospitalization, etc.). On the other hand, many see potential for a high return on investment in terms of health outcomes from advances in technology and health services if made more available in the developing world.

The evidence does not provide a definitive choice between prevention and treatment on economic grounds. There is economic evidence to support the cost-effectiveness of implementation on a wider scale of certain pharmaceutical strategies in developing countries (Gaziano et al., 2007). However, the issue of how best to approach implementation remains unresolved (Gaziano, 2007), which was also a central message of Chapter 5. There is

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

also an unresolved discussion between those who advocate for the targeting of patients with a single but high-risk factor (e.g., high blood pressure) and those arguing for an overall absolute risk approach (e.g., on the basis of 10-year risk of CVD), independent from the particular risk factor. These are debates on medical effectiveness, but they also spill over into the economic evaluation literature, as evidenced by the differences in therapeutic combinations and assessments of patient risks across the cost-effectiveness studies summarized in Table 7.5b at the end of this chapter. In addition, there has been limited economic evaluation of screening strategies, a necessary component of scaling up interventions to target individuals at high risk that is certainly not without cost. Therefore, considering the potential costs of scaling up and screening for risk factors as well as for delivering adequate supplies of drugs for persons identified through screening, there is still room for debate about whether pharmaceutical interventions are the right priority. In addition, factors such as the risk of adverse events in such a large untreated population, inequalities in access to care, and limited patient and system compliance need to be addressed.

Despite a general endorsement of scaling up pharmaceutical support from the economic perspective, it is also important to be mindful of the limitations of a strategy focused narrowly on pharmaceutical support. Clinically managed chronic care can be expensive and is often necessary for the remaining lifetime of an individual. In addition, clincial approaches targeted at segments of the population with higher risk (e.g., based on blood pressure) miss the typically large number of people below the threshold but nevertheless with risk factor-related ailments (Blackburn, 1983; Kottke et al., 1985; Puska et al., 1985; Schooler et al., 1997). A population-based approach, like one aiming for a reduction in salt intake, would at least in principle effect change in the entire population and not only those in the population at the highest risk, and in principle over the long term this could reduce the ultimate need for costly clinical interventions. This may render such population-based approaches attractive because of the rationale for a likelihood of cost-effectiveness over time, although the population risk reduction with these approaches can be limited (Neal et al., 2007).

In reality, the issue of prevention versus treatment is probably not the most useful question. The epidemic of CVD is not going to be addressed through the eradication of the disease in an entire population, the way one might hope to eradicate a disease with an acute infectious etiology. Instead, the goals for reducing the population burden of disease are that a greater proportion of the population can avoid developing the disease, that the average age of onset can be delayed, and that morbidity, mortality, and financial consequences due to CVD can be reduced. Indeed, the totality of the available epidemiological, intervention, and economic evidence support a balanced approach in which health promotion and prevention is

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

emphasized but which also recognizes the need for effective, appropriate, quality delivery of medical interventions for risk reduction and treatment. The distribution of investment in health promotion, prevention, and treatment approaches within that balance is something that will need to be determined based on the specific needs, capacity, and political and societal will of the stakeholder making the investment. The potential for improving the information available to inform this decision making is described in the final section of this chapter.

Costs to Address Gaps in CVD Needs3

One of the key questions asked by policy makers wishing to make investments to address an unmet health need is, “What will it cost?” The total cost to reduce the burden of disease is determined not only by the costs of interventions but also by the number of affected people in need of them. The difference between the proportion of the population that could benefit from intervention and that currently receiving such intervention is commonly called the “treatment gap.” This treatment gap can be defined in terms of any intervention approach, including population-based approaches and individual prevention or treatment. Determining the treatment gap depends on knowing four key parameters: prevalence in the population of a health condition; proportion of people with the condition that are treated and, conversely, the proportion that are not; proportion with the condition under control and, conversely the proportion not controlled; and cost of treatment. It is generally recognized that, particularly in developing countries, there are significant numbers of individuals who are in need but have not benefited from potentially effective and cost-effective interventions to treat or reduce risk for CVD and related chronic diseases. However, this treatment gap would need to be more specifically defined and linked to accurate cost information in order to more precisely determine the investment that would be required. This section of the chapter offers a discussion of illustrative evidence to demonstrate the analytic approaches available to determine what it will cost to reduce the burden of CVD in developing countries.

A short review was commissioned for this report of the treatment gaps in the developing world for CVD and related risk factors (Jan and Hayes, 2009).4 The objective of the review was to assess the feasibility of an approach to investment appraisal that brings together two sources of data:

3

This section is based in part on papers written for the committee by Stephen Jan and Alison Hayes and by Thomas Gaziano and Grace Kim.

4

The authors conducted a non-systematic search of the published and grey literature using PubMed and Google Scholar databases as well as hand-searches and snowballing. Search terms included “treatment gap and chronic diseases” and “treatment gap and cardiovascular disease.”

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

the nature and the scale of treatment gaps in CVD in developing countries and the costs and cost-effectiveness of a range of interventions. The review extracted evidence on treatment gaps from systematic reviews of treatment gaps for hypertension, comparative studies of risk reduction in individuals with CVD, and numerous studies of treatment gaps for specific diseases and risk factors in individual countries. A fair degree of standardization in the approaches taken to measuring treatment gaps enables some comparisons to be made across studies, but the appropriateness of generalizations about average overall rates is limited because the studies are derived from multiple sources across different settings and involve varying methodologies. In addition, although the available evidence establishes the treatment gap for some risk factors related to CVD, there remain methodological problems that make it difficult to reliably link the current evidence on treatment gaps with the current evidence on costs and cost-effectiveness in order to determine the total investment required to fill the treatment gap.

The studies extracted in this review provided sufficient information to assess treatment gaps in some countries for some risk factors for CVD, including hypertension, high cholesterol, and diabetes as well as ongoing risk reduction in individuals with CVD. The results show large treatment gaps. For other risk factors, such as obesity, lack of physical activity, and tobacco use, there is sufficient data to derive population estimates that indicate the potential numbers of individuals who could benefit from added intervention but not sufficient data on the numbers receiving interventions to determine a treatment gap.

For hypertension, a number of recent studies indicate that hypertension prevalence is on average around 30 percent of the adult population in developing countries, with a wide variation across settings, from 5 percent in rural India to 70 percent in Poland (Kearney et al., 2004). The available evidence indicates that around 30 percent of individuals with reported hypertension across developing countries are receiving treatment—thus a 70 percent treatment gap (Pereira et al., 2009). This gap varies not only across countries but also over time. For example, evidence from China indicates treatment levels at 17 percent in urban populations and 5 percent in rural populations in 1991 (Whelton et al., 2004), but levels were more recently observed at 28.2 percent overall in 2000-2001 (Gu et al., 2002). These variations demonstrate the difficulties with generalizing over time and across countries that are at differing stages of epidemiological and economic transition.

An interesting finding from the studies reviewed is that even in countries with relatively high proportions of patients getting treatment, the percent of hypertension under control is sometimes low. Across countries, around 30 percent of those receiving treatment in developing countries have their hypertension under control, which is similar to the rate of around 35 percent that has been observed in developed countries (Pereira et al., 2009).

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Although most studies review gaps in treatment using pharmaceutical interventions to reduce hypertension, recent evidence from China through the InterASIA study sheds some light on treatment coverage for nonpharmacotherapies. This study found that 47.2 percent of people with hypertension were using at least one of five nonpharmacological approaches, including salt reduction, weight loss or weight control therapies, exercise, alcohol reduction, and potassium supplementation at the time of the survey (Gu et al., 2002).

For cholesterol and diabetes, data is much less available than for hypertension. Evidence for both derives mainly from recent systematic reviews in China. The prevalence of moderate hypercholesterolemia (defined as ≥200 mg/dl total cholesterol) was 32.8 percent and the prevalence of high hypercholesterolemia (defined as ≥240 mg/dl total cholesterol or taking cholesterol lowering medications) was 9.0 percent. For those with moderately high cholesterol levels, 3.5 percent of men and 3.4 percent of women were receiving treatment, while 14 percent of men and 11.6 percent of women with very high cholesterol levels were receiving treatment. This suggests significant treatment gaps as high as 96 percent or 86 percent, depending on the criteria used for treatment (He et al., 2004). The prevalence of diabetes in China is around 5 percent, but only 20.3 percent are currently on treatment and 8.3 percent report being able to achieve control (Hu et al., 2008).

A study based on the WHO Study on Prevention of Recurrences of Myocardial Infarction and Stroke (PREMISE) project examined the level at which patients already diagnosed with coronary heart disease or cerebrovascular disease are being treated for ongoing risk-factor reduction. This study was conducted across 10 countries (Brazil, Egypt, India, Indonesia, Iran, Pakistan, Russia, Sri Lanka, Tunisia, and Turkey) and assessed patients’ awareness and uptake of lifestyle and pharmacological interventions (Mendis et al., 2005). Table 7.1a shows the percentage of patients with coronary heart disease and cerbrovascular disease on pharmaceutical interventions for risk reduction. For both conditions, the levels of medication use are highest for aspirin and lowest for statins. Also, although there was a high level of awareness of the benefits of various lifestyle interventions, uptake of these interventions was variable (Table 7.1b). Looking at a country-specific analysis, India was quite similar to the overall findings in terms of pharmaceutical interventions (Table 7.1c). However, another study in rural India showed much lower levels of patients on medication antiplatelet therapy, blood pressure-lowering drugs, and statins (Joshi et al., 2009) (Table 7.1d).

Estimated Costs to Fill the Hypertension Treatment Gap in 10 Countries

In addition to the review of the available literature described earlier, a modeling analysis of treatment gaps for hypertension and costs to achieve

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

TABLE 7.1a Patients on Medications in 10 Low and Middle Income Countries

 

Coronary Heart Disease

Cerebrovascular Disease

Aspirin

81.2%

70.5%

Beta-Blocker

48.1%

22.1%

ACE-Inhibitor

39.8%

38.1%

Statin

29.8%

12.2%

NOTE: WHO PREMISE data from Brazil, Egypt, India, Indonesia, Iran, Pakistan, Russia, Sri Lanka, Tunisia, and Turkey.

SOURCE: Mendis et al., 2005.

TABLE 7.1b Awareness and Uptake of Lifestyle Interventions in Patients in 10 Low and Middle Income Countries

 

Awareness of Benefits

Behavior

Smoking Cessation

82%

12% tobacco users

Healthful Diet

89%

35% did not follow healthful diet

Physical Activity

77%

52.5% less than 30 mins exercise/day

NOTE: WHO PREMISE data from Brazil, Egypt, India, Indonesia, Iran, Pakistan, Russia, Sri Lanka, Tunisia, and Turkey.

SOURCE: Mendis et al., 2005.

TABLE 7.1c Patients on Medications in India

 

Coronary Heart Disease

Cerebrovascular Disease

Aspirin

94.5%

90.1%

Beta-Blocker

46.2%

28.4%

ACE-Inhibitor

41.3%

23.5%

Statin

38.4%

37.0%

NOTE: WHO PREMISE data from India.

SOURCE: Mendis et al., 2005.

TABLE 7.1d Patients on Medications in Rural India

 

Coronary Heart Disease

Stroke

Antiplatelet (aspirin, copidogrel)

19.4%

11.8%

Blood Pressure-Lowering (beta-blocker,

41.1%

53.9%

ACE-Inhibitor, diuretic, and others) Statin

6.0%

1.0%

SOURCE: Joshi et al., 2009.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

reductions in blood pressure in select countries representing the different World Bank regions was commissioned for this report (Gaziano and Kim, 2009). This analysis was not focused on aggregated findings to determine global treatment gap and costs, but rather on country-specific analyses of the kind that might be most useful for decisions about funding and implementing country-specific policies and programs.

Based on a meta-analysis of published articles on nationally representative health surveys, Table 7.2 shows the prevalence, awareness, treatment, and control rates for hypertension in adult populations across 9 developing countries, including at least 1 country in each of the World Health Organization Developing World Regions, as well as in the United States as a comparison. Overall, control of hypertension is poor, with most countries having control rates of less than 15 percent. In the 10 countries examined in the commissioned analysis there were nearly 400 million individuals with hypertension, and it was currently controlled in fewer than 50 million (Gaziano and Kim, 2009).

The goal of the analysis was to provide, for each of the countries examined, an estimate of the likely total costs to address this “treatment gap” by achieving reduction of hypertension using one of two strategies. The first

TABLE 7.2 Global Prevalence, Awareness, and Control Rates for Hypertension

Country

Year

Age

Population (1000s)

% Prevalence

% Aware

% Treated

% Controlled

USA

1999-2004

≥18

187709

28.90

71.80

61.40

35.10

China

2000

35-74

476057

27.20

44.70

28.20

8.10

Czech Republic

2000-2001

25-64

5684

36.59

67.52

51.40

20.31

Mexico

2000

25-64

41695

33.30

25.20

12.90

3.70

Chile

2003

>17

11539

33.70

59.80

36.30

11.80

Iran

2005

25-64

28345

25.20

33.90

24.80

6.00

Egypt

1991-1993

≥25

36236

26.30

37.50

23.90

8.00

South Africa

1998

>15

28592

21.00

41.03

30.00

14.80

Pakistan

1990-1994

45-64

13634

30.82

17.61

9.40

3.04

India

2004

20-69

593906

28.00

51.50

50.00

7.00

NOTES: Hypertension is high blood pressure defined as systolic blood pressure/diastolic blood pressure over 140/90 mmHg and/or use of antihypertensive medication.

Awareness rate is the percentage of hypertensive individuals who were aware of their elevated blood pressure or had been told by a physician.

Control rate is the percentage of hypertensive individuals who successfully controlled their high blood pressure to below 140/90 mmHg.

Treatment rate is the percentage of hypertensive individuals were currently taking medications for their elevated blood pressure.

SOURCE: Gaziano and Kim, 2009.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

is a treatment program, where all individuals with hypertension would be treated and given medications to successfully control their high blood pressure. The second is a lifestyle change strategy aimed at reducing the mean blood pressure across the population. This analysis estimates only the cost of additional control and treatment programs; it does not report or evaluate current expenditures on efforts already implemented for drug treatment and population strategies to decrease blood pressure (Gaziano and Kim, 2009).

Table 7.3 shows the estimated total cost per country for the first approach, to treat and control all those with a blood pressure greater than 140 mmHg to a level below 140 mmHg, where the benefits of reducing risk are most robust. The estimate of costs reflects the overall population; the prevalence of hypertension; the blood pressure distribution in the country; and country-specific costs of care, including lab costs, health worker wages, use of facilities, and the costs of medication regimens administered according to current treatment guidelines and tailored to the starting blood pressure. It is important to note that this estimate only includes costs to achieve control once diagnosed and does not include the costs of screening, which would add necessary expenditures to identify those in need of treatment (Gaziano and Kim, 2009).

The total estimated cost that would be accrued to meet treatment needs is also shown in Table 7.3 as a percentage of the nation’s gross domestic product (GDP) in 2008 and as a percentage of the nation’s total health expenditures in 2006. The estimated costs relative to both GDP and total health expenditures show considerable variability across countries, with India and Chile standing out at the high end of the range.

TABLE 7.3 Estimated Annual Cost to Control Hypertension with Medication

Country

Total Population Cost of Controlling Hypertension (Intl $ millions)

% of GDP (2008, Intl $ millions)

% of Total Health Expenditures

USA

14,404

0.10

0.66

China

4,346

0.05

1.22

Czech Republic

200

0.08

1.14

Mexico

1,662

0.11

1.74

Chile

411

0.17

3.20

Iran

469

0.06

0.72

Egypt

254

0.06

0.91

South Africa

230

0.05

0.54

Pakistan

150

0.03

1.71

India

4,821

0.14

2.90

SOURCE: Gaziano and Kim, 2009.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

In summary, the available evidence from a sample of developing countries shows relatively low treatment coverage of the estimated at-risk population, with an even lower proportion of cases of hypertension under control. The costs that would need to be added to current health expenditures in order to address this unmet need are variable across countries. In some countries it may seem like a manageable shift in expenditures, whereas in others it is much higher. India is a particularly alarming case. The current estimate is that 28 percent of the population is hypertensive, but only half of those individuals are aware of their condition and half of that number receive treatment. Most alarmingly, only 7 percent of those treated have their blood pressure under control. Using current costs, it is estimated that India would need to add on additional spending of almost 3 percent of health care expenditures to control hypertension. This suggests that addressing the unmet needs for screening and effective treatment would require a much more effective health system to reduce those costs.

Hypertension can also be successfully averted through lifestyle and dietary changes, and implementing nation-wide strategies to promote lifestyle changes would possibly reduce mean blood pressure in a population. A population-wide strategy, by reducing the incidence of hypertension, could also produce cost reductions in the long term due to fewer patients requiring the treatment costs estimated above. The most reliable cost estimates currently available for population-based lifestyle changes to reduce hypertension are for salt-reduction strategies (Asaria et al., 2007). For the analysis commissioned for this report, a population-wide salt-reduction strategy assumed to result in a 3 mmHg reduction in mean population blood pressure was used to estimate the costs that would be accrued to achieve this in each country, as shown in Table 7.4 (Gaziano and Kim, 2009).

Combining population-based strategies with treatment approaches theoretically should produce some cost efficiencies, as one outcome of the population-based approaches would be to reduce the number in need of treatment. Successfully filling the treatment gap for hypertension could also potentially produce cost savings in the longer term by reducing not only the burden of CVD but also the burden of complications of other chronic diseases, such as diabetes and kidney failure.

This analysis provided an example of country-specific analyses of one risk factor for CVD. Further analyses using country-specific costs and treatment needs, taking into account other risk factors and other disease endpoints, would serve to inform the investment priorities of national governments and other stakeholders.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

TABLE 7.4 Estimated Total Cost to Achieve Mean Systolic Blood Pressure Reduction via Population Salt-Reduction Strategies (Intl $ millions)

Country

Total Population (2009, 1000s)a

3 mmHg Reductionb

USA

307,212

307.21

China

1,338,613

535.45

Czech Republic

10,212

4.08

Mexico

111,212

44.48

Chile

16,602

6.64

Iran

66,429

26.57

Egypt

78,867

31.55

South Africa

49,052

19.62

Pakistan

174,579

69.83

India

1,156,898

462.76

a U.S. Census International Database.

b Salt reduction: cost per individual is $1 for the United States,

$0.4 for all other countries.

SOURCE: Gaziano and Kim, 2009.

FUTURE NEEDS IN ECONOMIC ANALYSIS OF INTERVENTIONS5

As the previous sections demonstrate, economic analysis is a critical tool for evaluating different interventions to address CVD in developing countries, but there has been relatively little carried out in those settings, and what exists is not easily comparable (Behrman et al., 2009). Given the growing importance of CVD and other chronic diseases in developing countries, and the potential to seriously thwart or delay economic development—further research will be critical to determine, for specific countries, which investments are needed to address CVD and which investments are likely to produce the highest returns.

Conclusion 7.1: Governments need better health-sector and intersectoral economic analysis to guide decision making about resource allocations among health conditions and interventions.

This section details several high-priority areas for economic research on CVD.

5

This section is based in part on papers written for the committee by Stephen Jan and Alison Hayes, by Marc Suhrcke et al., and by Thomas Gaziano and Grace Kim.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Costs, Cost-Effectiveness, and Potential for Return on Investment in Public Health and Health Systems

The available evidence for low and middle income countries on cost-effectiveness of CVD interventions is informative and valuable, but scarce when compared to developed countries (Schwappach et al., 2007). Although the number of published economic evaluations of interventions for CVD in developing countries has increased substantially in recent years, beyond antitobacco strategies, the gaps in the evidence base limit the ability to conclude with confidence general recommendations that would apply to CVD in developing countries across countries and across all available intervention approaches. This is because there is a lack of primary economic analyses in developing countries, variation in costs and population health across countries, and reason to question whether and how the evidence-based strategies to prevent and manage CVD that have been shown to be cost-effective in developed countries are applicable in a developing-country context where resources are more limited and health care systems are less strong and more variable.

The available research studies are biased toward individual interventions, mostly pharmaceutical, targeted at persons with already established risk factors. Approaches using a population-based, public health intervention strategy, such as communications strategies or legislative actions, have not undergone cost-effectiveness analysis as extensively in developing-country contexts, especially using primary effectiveness data. However, the available studies do show promise for the likely cost-effectiveness of these approaches. There are even fewer cost-effectiveness studies from developing countries on multi-level and multi-valent CVD interventions.

Therefore, as described in the following section, there is a pressing need for research efforts to improve methodologies to evaluate the transferability of cost-effectiveness evidence from developed to developing settings and to increase the primary evidence base for cost-effectiveness evaluations in developing-country settings. There is also a need to expand economic analyses to be more inclusive of countries and regions that have a high burden of disease but are not well represented in the available economic literature, such as former Soviet Republics and the Middle East. Increasing the research in these and other neglected regions should be part of an international global health strategy to address CVD.

Improving the Use of Modeling to Transfer Cost-Effectiveness Evidence from Developed to Developing Countries

It is not realistic to expect primary economic evaluations to be conducted for every intervention in every developing country. The use of modeling methodologies to transfer results from developed to developing

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

countries and between developing countries, as well as to estimate long-term effects, remains a necessary alternative that has and will continue to be highly informative, as described earlier in this chapter. However, there are several major challenges to using this approach to guide implementation choices at the national level in low and middle income countries. These include differences in health care costs across countries, differential effectiveness of interventions in different settings, differential disease prevalence, differential valuation of outcomes, and differential efficiency in implementing interventions. As a result, the applicability of economic modeling results is highly dependent on the methods applied and the assumptions that are incorporated in the model.

Broadly speaking, there is a need to improve modeling methods to take into account the potential effects, including regional/country-level variations, of demographics, epidemiological transition, emerging changes in availability of technology, and financial conditions. In particular, there are two key areas that emerge as a priority to improve models used to evaluate interventions to address CVD.

First, the available modeling analyses almost exclusively calculate effectiveness based on studies conducted in developed countries. Therefore, there is a great need to perform effectiveness studies in developing-country settings and for these results to inform economic models. This is especially important for interventions targeted to changing health behaviors and those that use methods such as communications, which are highly dependent on cultural and infrastructural characteristics. In addition, for interventions to target high-risk individuals, the effectiveness of strategies for screening/ identification must be taken into account. The predominance of the use of developed-country effectiveness data in these models is due primarily to the lack of effectiveness data for CVD interventions in developing countries, as has been described in Chapters 5 and 6. Efforts to fill this knowledge gap will also serve to improve the quality of economic analyses by making more relevant secondary data available.

Second, and similarly, many models calculate resource utilization based on implemented data from developed countries. Therefore, there is also a great need for modeling that instead calculates resource utilization based on implemented data from developing-country settings. This is true for all types of interventions. Even interventions for which effectiveness data is arguably more readily transferred across populations and stage of development (such as pharmaceutical interventions), developing-country settings will have vastly different implementation resources and infrastructure. Addressing this gap will require greater research efforts to project, or ideally measure, the actual costs of implementing interventions in at least a representative sample of developing countries. This includes realistic assessments of the costs of implementing non-clinical primary prevention and population-based strategies in these settings, the true costs of which can be very difficult to

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

determine. As above for effectiveness, this also means that to conduct realistic assessments of the costs of interventions to target high-risk individuals, costs of screening/identification must be taken into account.

Although the challenges of transferring evidence using modeling methodologies is acknowledged by both the Disease Control Priorities Project (Musgrove and Fox-Rushby, 2006) and the WHO CHOICE project (Evans and Ulasevich, 2005), there are currently no validated methodologies or consensus guidelines within the scientific community on how to handle this uncertainty in modeling interventions for developing countries. Consensus standards for conducting and reviewing evaluations among researchers and journals in the field could elevate the quality of evidence and allow for greater comparability across studies. A potential model for such standards could come from the task force on research practices in modeling studies of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) (Weinstein et al., 2003). At a minimum, the capacity for this kind of data to be useful for policy decisions would be greatly improved if information about the assumptions influencing the model and the sources of secondary data were more clearly stated in the published literature. In both reviews commissioned by this committee, for example, the authors found that there was a lack of full information in many modeling studies.

Increasing the Evidence Base of Primary Economic Analyses of Interventions Conducted in Developing-Country Settings

Modeling methodologies to transfer results from developed to developing countries and between developing countries will continue to be an important approach to assessing the most cost-effective ways to address CVD. However, it is also a crucial goal to increase the evidence base of primary economic analyses from developing countries. Once again, this relates directly to the need for more primary intervention evidence from developing countries. Therefore, it is important that steps taken to increase effectiveness and implementation research in these countries be accompanied by an emphasis on conducting economic analyses as part of the evaluation, especially for population-based and public health approaches such as community-based interventions, communications strategies, or legislative actions. These are areas where economic evidence is lacking and the specificity of the setting potentially has the largest impact on effectiveness. This should be an achievable goal if made a priority by global health funders (see Chapter 8).

Making the Evidence More Useful for Policy Makers

Few of the currently available economic analyses adopted a comprehensive perspective in their analysis. In general, the more comprehensive a

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

study is, the easier it is for decision makers to compare the intervention to other alternatives available for funding. In developing countries, budgets are highly constrained, and not only is CVD competing with other health priorities, but also all investments in health care are in crucial competition with other budgetary sectors, such as education or public infrastructure. A greater focus on comprehensive evaluations would facilitate policy decisions.

One way to address this is through the expression of health benefits in comprehensive units (such as “life-years gained” or the surrogate measure of QALYs or DALYs) rather than CVD-specific measures that may be easier to measure but are difficult to compare to other interventions within or outside the health care sector. In addition, the utility to policy makers can be improved through the use of methods such as benefit–cost analysis, which offers the capability of expressing all benefits of an intervention, occurring in the health care sector or not, in monetary units. With respect to affordability and adherence to treatment, the use of willingness to pay approaches could also be informative, especially in health care systems in which patients are required to contribute some or all of the costs. For example, in a rare willingness-to-pay analysis from a developing country, patients in China were not willing to pay the annual cost of $73 for anti-hypertensive medicine until their 5-year absolute risk for CVD exceeded 35 percent (Tang et al., 2009).

This also applies to the economic perspective applied in the analysis, which relates to the question of who will incur the costs of an intervention and who will receive the benefits. Key perspectives that are relevant to policy makers include, for example, the health care provider, the patient, the government, third-party payers, and the societal perspective, which has not yet been explicitly applied to the evaluation of interventions for CVD in the developing world.

Defining Resource Needs

As described in this chapter, there has not been sufficient analysis to determine what it will cost to reduce the burden of CVD in developing countries. Ideally, this type of analysis—linking evidence of prevention and disease management needs (the “treatment gap”) with evidence of costs and cost-effectiveness—would be carried out at a country level to inform the implementation of interventions to address high-priority health conditions. If provided within a specific macroeconomic and epidemiological context, it would give decision makers an indication of not only what options represent the “best buys” but also how investment in such buys is anticipated to contribute to a reduction in the overall burden of disease. For instance it would indicate that, for a defined population, $X invested in treatment Y would be needed to eliminate a particular treatment gap. Health

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

and finance policy makers would then have clear guidance on where to shift resources to achieve the maximum health benefit. There is very limited available evidence for this type of health investment appraisal. Therefore, there needs to be an ongoing program of research in this area, especially given the rapid changes over time in risk-factor prevalence, treatment levels (and gaps), technology, and costs of treatment.

Recommendation: Define Resource Needs


The Global Alliance for Chronic Disease should commission and coordinate case studies of the CVD financing needs for five to seven countries representing different geographical regions, stages of the CVD epidemic, and stages of development. These studies should require a comprehensive assessment of the future financial needs within the health, public health, and agricultural systems to prevent and reduce the burden of CVD and related chronic diseases. Several scenarios for different prevention and treatment efforts, technology choices, and demographic trends should be evaluated. These assessments should explicitly establish the gap between current investments and future investment needs, focusing on how to maximize population health gains. These initial case studies should establish an analytical framework with the goal of expanding beyond the initial pilot countries.

A number of considerations should be taken into account for these studies and other future research to accurately project costs to address untreated CVD. First, as mentioned earlier, if estimates of treatment gaps are to offer specific guidance to decision makers they must be contextualized based on local circumstances—including demographics, epidemiological transition, and financial conditions—and must be provided in conjunction with cost and cost-effectiveness analysis. The reasons for treatment gaps are likely to be varied and differ according to context and intervention. Factors such as cost, geographical access, availability of treatment technologies, and provider incentives are likely to be significant determinants. At present the treatment gap literature focuses mainly on patient awareness. Further work should be conducted into investigating the broader determinants of treatment gaps because they are crucial in establishing any policy response.

Second, existing evidence of treatment gaps generally focuses on a single risk factor. However, ideally this assessment would take into account multiple risk factors based on an absolute risk approach. This includes reorienting risk-factor prevalence studies so that they are based on absolute risk rather than on the prevalence of a single risk factor. This would also allow such studies to be better linked with most of the available cost-

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

effectiveness evidence. However, it is important to consider that risk-factor measures required by models such as the risk assessment tool based on the Framingham Study may not always be available or may be cost-prohibitive in a low income setting (e.g., if they include lab tests). These measures also may not be readily applicable to different populations in developing countries. A priority for future research is the development of specific risk-prediction screening tools appropriate for low income settings and for such forms of risk stratification to then be reflected in cost-effectiveness and treatment gap analysis.

In addition, the role of system constraints in determining treatment gaps needs to be assessed (e.g., geographical and financial constraints on access to health care; human resource constraints such as lack of staff, misaligned incentives for providers, lack of infrastructure, and inadequate regulatory systems), as well as the effectiveness and cost-effectiveness of addressing these constraints. Better information is also needed on the extrapolation of cost-effectiveness estimates in relation to the scaling up of interventions to meet the treatment gap. Assumptions made in economic modeling of constant returns to scale and of continued and constant treatment effect are currently not well supported by evidence. Finally, studies on costs and cost-effectiveness of interventions to address CVD are generally health sector-specific. Further research is required to investigate intersectoral approaches that work beyond conventional health-sector boundaries as potential innovations in interventions to address the treatment gap.

CONCLUSION

Given limited resources and political energy to allocate to CVD programming, many countries will want to focus their efforts on goals that are economically feasible, have the highest likelihood of intervention success, and have the largest morbidity impact. The limitations on the available evidence do not preclude intervening now as initial priorities can be ascertained. Indeed, the totality of intervention and economic analysis suggests that substantial progress in reducing CVD can be made in the near term through a prioritized subset of intervention approaches—if they can be successfully and efficiently adapted and implemented. These include staretegies for tobacco control, reduction of salt in the food supply and in consumption, and improved delivery of clinical prevention using pharmaceutical interventions in high-risk patients, especially if linked to existing health systems strengthening efforts. The evidence for lowered CVD morbidity associated with achieving these priority goals is credible, there are examples of successful implementation of programs in each of these focus areas with the potential to be adapted for low and middle income countries, and economic analyses have shown that they are likely to be cost-effective.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

TABLE 7.5a Summary of Economic Analyses for Population-Based and Other Lifestyle CVD Intervention Approaches for Low and Middle Income Countries

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Tobacco Controlb

 

 

 

 

 

Lai et al., 2007

Estonia

Increase taxes from 49% to 60%

Current situation

 

 

Estonia

Taxes and advertising bans on smoking

Taxes only

 

 

Estonia

Taxes, ad ban, and clean indoor air

Taxes and ad ban

 

Gaziano, 2008

Sub-Saharan Africa

Tobacco taxation—price increase 33%

Null

 

 

Sub-Saharan Africa

Tobacco regulation (non-price intervention such as labeling, advertising bans)

Null

Thavorn and Chaiyakunapruk, 2008

Thailand

Individual health education for tobacco cessation

Usual care: screening and brief advice and support

a Sources of data on intervention effectiveness and costs for modeling assumptions vary widely across studies and in some cases are drawn from high income country information.

b For tobacco control, see also reviews by Chisholm et al., 2006; Jha et al., 2006; and Shibuya et al., 2003.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methoda

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost Effective?

WHO CHOICE Modeling

Assumed 3.4% decline in tobacco consumption

ICER: 218 EEK/DALY averted

Y

<per capita GDP (90454 EEK)

WHO CHOICE Modeling

Assumed 3.4% decline in tobacco consumption PLUS 5% decline in new smokers

ICER: 304 EEK/DALY

Y

WHO CHOICE Modeling

Assumed 3.4% decline in tobacco consumption PLUS 5% decline in new smokers PLUS 5% decline in the incidence of smoking among male smokers, and 2.4% decline among female smokers

ICER: 453 EEK/DALY

Y

Modeling

Assumed a reduction in future tobacco deaths of 5.4%-15.9%

ICER: US$2-26/DALY

Not reported

Modeling

Assumed a reduction in future tobacco deaths of 1.6%-7.9%

ICER: US$33-417/DALY

Not reported

Modeling

Assumed a 14.3% smoking cessation rate (with no relapse) with a corresponding assumed reduction in events and mortality due to COPD, AMI, CHF, angina, and stroke

Cost savings of 17503 baht (£250; 325; US$500) to the health system and life year gains of 0.18 years for men

Cost savings of 21 499.75 baht (£307; 399; $614) and life year gains of 0.24 years for women

Y

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Food Regulation

 

 

 

 

 

Rubinstein et al., 2009

Argentina (Buenos Aires)

Regulation of salt content of bread

Null

 

Murray et al., 2003

Latin America

Salt reduction—industry agreements

Null

 

 

Latin America

Salt reduction—legislation

Null

 

 

South-East Asia

Salt reduction—industry agreements

Null

 

 

South-East Asia

Salt reduction—legislation

Null

 

Gaziano, 2008

Sub-Saharan Africa

Substitution of polyunsaturated fats for 2% of dietary transfats

Null

Physical Activity

 

 

 

 

 

Matsudo et al., 2006

Brazil

Population-based physical activity promotion

 

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methoda

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost Effective?

Modeling Popmod (WHO)

Assumed that a 1g of salt reduction per 100g of bread led to a reduction of 1.33mmHg in systolic blood pressure per person and 1% of the population-attributable risk of CHD and stroke

ICER: 151 ARG$/DALY

Y Based on <3× per capita GNI

Popmod multistate modeling

Assumed blood pressure changes specific for region, age, and sex associated with a 15% reduction in total dietary salt intake

Average CER: US$24/DALY

Y based on < per capita GDP

Popmod multistate modeling

Assumed blood pressure changes specific for region, age, and sex associated with a 30% reduction in total dietary salt intake

Average CER: US$13/DALY

Y

Popmod multistate modeling

Assumed blood pressure changes specific for region, age, and sex associated with a 15% reduction in total dietary salt intake

Average CER: US$37/DALY

Y

Popmod multistate modeling

Assumed blood pressure changes specific for region, age, and sex associated with a 30% reduction in total dietary salt intake

Average CER: US$19/DALY

Y

Popmod multistate modeling

Assumed reduction in CAD of 7% to 40%

ICER: US$53-1344/ DALY at 7% Cost saving US$ –184 at 40%

Y

Modeling

Assumptions for model unknown

Cost Utility Analysis: Cost saving

Y

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Physical Activity (cont.)

Salvetti et al., 2008

Brazil

Home-based training for physical post-MI

Standard care

Health Education

 

Murray et al., 2003

South-East Asia

Health education focusing on lowering BMI and cholesterol

Null

 

 

Latin America

Health education focusing on lowering BMI and cholesterol

Null

 

Getpreechaswas et al., 2007

Thailand

Social marketing through trained health personnel, village health volunteers, and family health leaders

Interview only

 

García-Peña et al., 2002

Mexico

Health education in home visits by nurse to elderly people with hypertension

No intervention

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methoda

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost Effective?

RCT

Overall biomedical measures of cardiovascular function and self-reported measures of quality of life improved in the intervention group and remained constant or worsened in the control group

Protocol cost $502.71 (BHCMP) per patient for 3 months

Not reported

Popmod multistate modeling

Assumed a 2% reduction in total blood cholesterol concentrations

Average CER: US$14/DALY

Y based on < per capita GDP

Popmod multistate modeling

Assumed a 2% reduction in total blood cholesterol concentrations

Average CER: US$14/DALY

Y

Observational trial

The intervention group showed a significant improvement in dietary patters, physical activity, and stress reduction and a significant decrease in tobacco and alcohol use compared to the control group

Costs: 74.89 baht per head of population

Not reported

RCT

A reduction of 3.31 mm Hg in SBP and 3.67 mm Hg in DBP in the intervention group compared to the control group. In the intervention group, 12.9% of participants reported an increase in brisk walking, compared with 5.2% in the control group. The proportion of people on anti-hypertensive medication decreased from 28.4% to 15.9%, compared to a decrease from 32.2% to 26.9% in the control group

CER: 10.46 pesos (US$1.14) per mmHg reduced for SBP

9.43 (US$1.03) per mmHg reduced for DBP

Not possible to conclude

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Huang et al., 2000, and

Chen et al., 2008

Beijing China

Community-based CVD program including education and risk-targeted high blood pressure medication (Beijing Fangshan CVD Prevention Program)

Null

 

Rubinstein et al., 2009

Argentina (Buenos Aires)

Health education through mass media

Null

 

Rossouw et al., 1993

South Africa

Social Marketing (CORIS)

No intervention

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methoda

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost Effective?

Observational cohort

Observed a net reduction in SBP/DBP in the intervention group compared to the control group of –1.4/.05 mmHg in men and –3.4/–1.0 in women. Observed a reduction in morbidity and mortality of stroke of 18.7% in the intervention group compared to 17.7% in the control group. Observed a reduction in morbidity and mortality of CHD of 4.9% in the intervention group compared to 4.3% in the control group.

ICER: 1992 1586 yuan/DALY 1993 1380 yuan/ DALY

ICER: Cost saving from 1994-1997

Cost saving

Modelling Popmod (WHO)

Assume a reduction of 1.83mmHg in systolic blood pressure and 0.02mm/l in cholesterol (t), leading to a reduction of 2% of the population attributable risk of CHD and stroke

ICER: 547 ARG$/DALY

Y Based on <3× per capita GNI

Observational trial

For men there was a reduction in risk score of 1.3% in the control group, 3.7% in the low-intensity intervention group, and 3.7% in the high-intensity intervention group

For women there was a reduction in risk score of 1.6% in the control group, 4.7% in the low-intensity intervention group, and 4.4% in the high-intensity intervention group

$5 per capita cost for low intensity; $22 per capita cost for high intensity

Not reported

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Multiple Strategies

Asaria et al., 2007

Multinational

Population-based strategies to reduce salt consumption by 15% and a 43.2% increase in the price of tobacco combined with non-price interventions

No treatment

NOTE: AMI = Acute Myocardial Infarction; CAD = Coronary Artery Disease; CER = Cost-Effectiveness Ratio; CHD = Coronary Heart Disease; CHF = Congestive Heart Failure; COPD = Chronic Obstructive Pulmonary Disease; CVD = Cardiovascular Disease; DALY = Disability-Adjusted Life Year; GDP = Gross Domestic Product; GNI = Gross National Income; ICER = Incremental Cost-Effectiveness Ratio; RCT = Randomized Controlled Trial; WHO = World Health Organization.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methoda

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost Effective?

Modeling

Salt Reduction Assumed the reduction in salt intake lead to an age-stratified decrease in mmHg of SPB of 1.24 (30-44), 1.7 (45-59), 2.34 (60-69), 2.83 (70-79), 3.46 (80-100)

Tobacco prices Assumed the non-price interventions lead to a 12% decrease in smoking prevalence Assumed the increase in price of tobacco lead to a 20.8% decrease in smoking prevalence

Costs range from US$0.14-1.04 per person per year to avert approximately 13.8 million deaths from CVD, respiratory disease, and cancer over 10 years

Not reported

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

TABLE 7.5b Summary of Cost Effectiveness Evidence for Pharmaceutical Intervention Approaches Against Cardiovascular Disease for Low and Middle Income Countries

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Pharmaceutical

 

 

 

 

 

Lim et al., 2007

Multi-national

Secondary prevention (aspirin, ACE-inhibitor, β-blocker, statin)

Primary prevention targeted to high risk (aspirin, ACE-inhibitor, thiazide, statin)

No treatment

 

Gaziano et al., 2006

East Asia and the Pacific

Secondary prevention (aspirin, β-blockers, ACE-inhibitor, statins)

Null

 

 

East Europe and Central Asia

Secondary prevention (aspirin, β-blockers, ACE-inhibitor, statins)

Null

 

 

Latin America and Caribbean

Secondary prevention (aspirin, β-blockers, ACE-inhibitor, statins)

Null

 

 

Middle East and North Africa

Secondary prevention (aspirin, β-blockers, ACE-inhibitor, statins)

Null

South Asia

Secondary prevention (aspirin, β-blockers, ACE-inhibitor, statins)

Null

a Sources of data on intervention effectiveness and costs for modeling assumptions vary widely across studies and in some cases are drawn from high income country information.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Modeling

Assumed achievement of a 50% drug coverage rate in the more constrained countries

Assumed achievement of an 80% coverage rate in the less constrained countries

Assumed between 40% and 60% drug adherence

Financial resources needed to scale up average $5 billion per year, or $1.08 per head per year

Not reported

Markov model

Assumed a 7% reduction in lifetime risk for CVD

ICER: US$336/QALY

Y based on <3 per capita GNI

Markov model

Assumed a 15% reduction in lifetime risk for CVD

ICER: US$362/QALY

Y

Markov model

Assumed a 12% reduction in lifetime risk for CVD

ICER: US$388/QALY

Y

Markov model

Assumed a 15% reduction in lifetime risk for CVD

ICER: US$341/QALY

Y

Markov model

Assumed a 13% reduction in lifetime risk for CVD

ICER: US$306/QALY

Y

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Sub-Saharan Africa

Secondary prevention (aspirin, β-blockers, ACE-inhibitor, statins)

Null

 

 

East Asia and the Pacific

Primary prevention absolute risk 5% and 25% (aspirin, calcium channel blocker, ACE-inhibitor, statin)

Null

 

 

East Europe and Central Asia

Primary prevention absolute risk 5% and 25% (aspirin, calcium channel blocker, ACE-inhibito, statin)

Null

 

 

Latin America and Caribbean

Primary prevention absolute risk 5% and 25% (aspirin, calcium channel blocker, ACE-inhibitor, statin)

Null

 

 

Middle East and North Africa

Primary prevention absolute risk 5% and 25% (aspirin, calcium channel blocker, ACE-inhibitor, statin)

Null

 

 

South Asia

Primary prevention absolute risk 5% and 25% (aspirin, calcium channel blocker, ACE-inhibitor, statin)

Null

Sub-Saharan Africa

Primary prevention absolute risk 5% and 25% (aspirin, calcium channel blocker, ACE-inhibitor, statin)

Null

 

Amira and Okubadejo, 2006

Nigeria

Pharmaceutical treatment of hypertension; Targeted to high risk

Respective drug

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Markov model

Assumed a 9% reduction in lifetime risk for CVD

ICER: US$312/QALY

Y

Markov model

Assumed a 54% and 40% reduction in lifetime risk for CVD

ICER: US$1214/QALY US$890/QALY

Y

Markov model

Assumed a 43% and 30% reduction in lifetime risk for CVD

ICER: US$1207/QALY US$858/QALY

Y

Markov model

Assumed a 53% and 32% reduction in lifetime risk for CVD

ICER: US$1219/QALY US$881/QALY

Y

Markov model

Assumed a 50% and 29% reduction in lifetime risk for CVD

ICER: US$1221/QALY US$872/QALY

Y

Markov model

Assumed a 50% and 27% reduction in lifetime risk for CVD

ICER: US$1039/QALY US$746/QALY

Y

Markov model

Assumed a 59% and 32% reduction in lifetime risk for CVD

ICER: US$1145/QALY US$771/QALY

Y

Other

Blood pressure control was achieved in 39.6% of the target population

Most cost-effective was coamiloride with CER 42.9, least was combination CCB with ACEI, CER 3145.2

See comparison result

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Rubinstein et al., 2009

Argentina (Buenos Aires)

Treatment of hypertension (lifestyle change promotion and hydrochlorothiazide, atenol, enalapril);

Not risk targeted

Null

 

 

Argentina (Buenos Aires)

Treatment of high cholesterol (low cholesterol diet plus statin)

Not risk targeted

Null

 

 

Argentina (Buenos Aires)

Polypill based on three different target populations (risk determined with Framingham equations) 20% CVD risk

Null

 

 

Argentina (Buenos Aires)

As above—10% CVD risk

Null

Argentina (Buenos Aires)

As above—5% CVD risk

Null

 

Robberstad et al., 2007

Tanzania

Diuretic hydrochlorothiazide; Not risk targeted

Null

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Modeling Popmod (WHO)

Assumed that 40% of the population would take one drug, 40% at least two drugs, and 20% three or more drugs

Assumed a 50% rate of disease detection and drug compliance leading to a reduction in the population-attributable risk of CVD and stroke by 8%

ICER: 7716 ARG$/DALY

N

Modeling Popmod (WHO)

Assumed reduction of cholesterol to less than 240mg/dl, (6.2mm/l) leading to a reduction of 8% of the population-attributable risk of CHD and stroke

Assumed a 50% detection and drug compliance rate

ICER: 70994 ARG$/DALY

N

Modeling Popmod (WHO)

Assumed a reduction of population-attributable risk of CHD and stroke of 60%

Assumed an 80% detection and drug compliance rate

ICER: 3599 ARG$/DALY

Y Based on <3× per capita GNI

Modeling Popmod (WHO)

Assumed a reduction of population-attributable risk of CHD and stroke of 40%

Assumed a 50% detection and drug compliance rate

ICER: 4113 ARG$/DALY

Y Based on <3× per capita GNI

Modeling Popmod (WHO)

Assumed a reduction of population-attributable risk of CHD and stroke of 15%

Assumed a 50% detection and drug compliance rate

ICER: 4533 ARG$/DALY

N

Life cycle Markov model

Assumed 1.6 life years saved and a very high risk population

ICER: US$85/DALY

Y based on < per capita GDP of $300

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Tanzania

Aspirin + diuretic hydrochlorothiazide; Not risk targeted

Null

 

 

Tanzania

Aspirin, diuretic, β-blocker; Not risk targeted

Null

 

 

Tanzania

Aspirin, diuretic, β-blocker, statin; Not risk targeted

Null

 

 

Tanzania

Hypothetical polypill; Not risk targeted

Null

 

Moreira et al., 2009

Brazil

Treatment of hypertension with diuretics

Null

 

 

Brazil

Treatment of hypertension with β-blockers

Null

 

 

Brazil

Treatment of hypertension with ACEI

Null

 

Gaziano, 2005

South Africa

Targeted drug treatment based on blood pressure 160/95mmHg

No treatment

 

 

South Africa

Targeted drug treatment based on blood pressure 140/90mmHg

No treatment

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Life cycle Markov model

Assumed 3.1 life years saved and a very high risk population

ICER US$143/DALY

Y based on < per capita GDP of $300

Life cycle Markov model

Assumed 3.6 life years saved and a very high risk population

ICER US$317/DALY

N

Life cycle Markov model

Assumed 5.4 life years saved and a very high risk population

ICER US$999/DALY

N

Life cycle Markov model

Assumed 6.3 life years saved and a very high risk population

ICER US$1476/DALY

N

Observational cohort >40 years

Observed a 56.6% blood pressure control rate

Average CER: US$15.5 (total monthly cost/controlled patients)

Not reported

Observational cohort >40 years

Observed a 66.4% blood pressure control rate

Average CER: US$34.7

Not reported

Observational cohort >40 years

Observed a 44.8% blood pressure control rate

Average CER: US$176.7

Not reported

Markov CVD model

Treatment was assumed to lead to a 10mmHg reduction in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD

Dominated

N

Markov CVD model

Treatment was assumed to lead to a 10mmHg reduction in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD

Dominated

N

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

South Africa

Targeted drug treatment based on 10-year absolute CVD risk >40%

No treatment

 

 

South Africa

Targeted drug treatment based on 10-year absolute CVD risk >30%

Treatment at 40% risk

 

 

South Africa

Targeted drug treatment based on 10-year absolute CVD risk >20%

Treatment at 30% risk

 

 

South Africa

Targeted drug treatment based on 10-year absolute CVD risk >15%

Treatment at 20% risk

Shafiq et al., 2006

India

Low molecular weight heparin in patients with unstable angina

No treatment

 

Murray et al., 2003

Latin America

Hypertension treatment (β-blocker, diuretic) and education; Not risk targeted

No treatment

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Markov CVD model

Treatment was assumed to lead to a 10mmHg reduction in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD

ICER: US$700/QALY

Y Based on <US$9000/ QALY (3× per capita GDP)

Markov CVD model

Treatment was assumed to lead to a 10mmHg reduction in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD

ICER: US$1600/QALY

Y

Markov CVD model

Treatment was assumed to lead to a 10mmHg reduction in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD

ICER: US$4900/QALY

Y

Markov CVD model

Treatment was assumed to lead to a 10mmHg reduction in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD

ICER: US$11000/QALY

N

Prospective RCT

Primary endpoints of death, MI, or angina occurred in 24% to 30% of patients

ICER: US$54.72 to US$119.91/ composite endpoint

See comparison result

Popmod multi-state modeling

Assumed a 33% reduction in difference between the actual SBP and 115mm Hg

Average CER: US$81/DALY

N Based on < per capita GDP

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/ Setting

Intervention

Comparator

Latin America

High cholesterol treatment (statins) and education; Not risk targeted

No treatment

 

 

Latin America

Blood pressure and cholesterol treatment and education; Not risk targeted

No treatment

 

 

Latin America

Treatment based on absolute risk (>35% risk in 10 years)

No treatment

 

 

South-East Asia

Hypertension treatment (β-blocker, diuretic) and education; Not risk targeted

No treatment

 

 

South-East Asia

High cholesterol treatment (statins) and education; Not risk targeted

No treatment

 

 

South-East Asia

Blood pressure and cholesterol treatment and education; Not risk targeted

No treatment

 

 

South-East Asia

Treatment based on absolute risk (>35% risk in 10 years)

No treatment

 

Ker et al., 2008

South Africa

Pharmaceutical interventions with tobacco cessation

No treatment

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Popmod multi-state modeling

Assumed a 20% reduction in total blood cholesterol

Average CER: US$87/DALY

N

Popmod multi-state modeling

Assumed a 33% reduction in difference between the actual SBP and 115mmHg and a 20% reduction in total blood cholesterol

Average CER: US$183/DALY

N

Popmod multi-state modeling

Assumed a 33% reduction in difference between the actual SBP and 115mmHg, a 20% reduction in total blood cholesterol, and an additional 20% reduction of absolute risk for antiplatelet therapy

Average CER: US$37/DALY

Y

Popmod multi-state modeling

Assumed a 33% reduction in difference between the actual SBP and 115mmHg

Average CER: US$36/DALY

N

Popmod multi-state modeling

Assumed a 20% reduction in total blood cholesterol

Average CER: US$47/DALY

N

Popmod multi-state modeling

Assumed a 33% reduction in difference between the actual SBP and 115mmHg and a 20% reduction in total blood cholesterol

Average CER: US$84/DALY

N

Popmod multi-state modeling

Assumed a 33% reduction in difference between the actual SBP and 115mmHg, a 20% reduction in total blood cholesterol, and an additional 20% reduction of absolute risk for antiplatelet therapy

Average CER: US$33/DALY

Y

Modeling

Assumed an absolute risk reduction of 7% to 22%

Costs per % of risk reduction ranges from R12.7 to R23.84

Not reported

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/Setting

Intervention

Comparator

Rubinstein et al., 2009

Argentina (Buenos Aires)

Tobacco cessation therapy (bupropion)

Null

 

Redekop et al., 2008

Poland

Prevention of CVD endpoints with perindopril in CHD patients

Placebo

 

Wessels, 2007

South Africa

Prevention of cardiovascular or cerebrovascular events with eprosartan in stroke patients

Use of amlodipine and perindopril

 

Dias da Costa et al., 2002

Brazil

Treatment of hypertension with diuretics, β-blockers, calcium channel blockers, and ACE-inhibitors

Alternative drugs

 

Anderson et al., 2000

South Africa

Treatment with angiotensin II type 1 receptor blockers in patients with mild to moderate hypertension

Alternative drugs

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Modeling Popmod (WHO)

Assumed a reduction of 4% of the population-attributable risk of CHD and stroke

ICER: 33563 ARG$/DALY

N

Combined Trial-modeling

Observed a 1.88% decrease in risk of primary endpoints. Increase of .182 years life expectancy

ICER of PLN10896 per life year gained

Highly likely to be Y (<PLN60000)

Modeling

Assumed prevention of 23 CVD events per 1000 patients and 29.1 CBV events per 1000 patients

Cost-utility analysis of eprosartan estimated cost saving of ZAR 53132/QALY compared with amlodipine, and a cost saving of ZAR 72888 compared with perindopril

Y based on < per capita GDP

Population survey

Percent of patients using a drug category whose hypertension was controlled (<160mmHg SBP) Diuretics: 54.9% β-blockers: 71% ACE-inhibitors: 52% Calcium channel blockers: 80%

Cost-effectiveness relationship (ratio of annual mean cost to proportion of patients using drug/drug combination whose hypertension was controlled) Diuretics: 116.3 β-blockers: 228.5 ACEI: 608.5 Calcium channel blockers: 762

See comparison result

Modeling

Assumed reduction in SDBP for each drug of candesartan 10.57mmHg irbesartan 9.07mmHg losartan 8.89mmHg valsartan 7.11mmHg

Reduction in SDBP per R100 spent: candesartan was most cost-effective at 4.48 mmHg/R1OO; losartan was 3.77; irbesartan was 3.37; valsartan was 3.04mmHg Cost to achieve 1mmHg reduction in SDBP: candesartan (R22.34/mmHg); losartan (R26.54/mmHg); irbesartan (R29.65/mmHg); valsartan (R32.86/mmHg)

See comparison result

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/Setting

Intervention

Comparator

Edwards et al., 1998

South Africa

Reducing availability for routine prescribing of less cost-effective antihypertensive drugs or drug combinations

Current drug treatment

 

Oyewo, 1989

Nigeria

Treatment of hypertension with antihypertensives

Respective alternative drug

Treatment and Prevention of Cardiac Events

 

Biccard et al., 2006

South Africa

Use of β-blocker or statin following surgery to avoid cardiovascular complications in patients with >10% risk

Placebo

 

Orlewska et al., 2003

Poland

Treatment with enoxaparin in acute coronary syndrome

 

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Observational trial

Observed blood pressure control did not change

Monthly cost per patient decreased 24.2% due to decrease in prescriptions of less cost-effective drugs for more cost-effective drugs

Not applicable

Cross-sectional

Efficacy coded based on systolic blood pressure reduction observed

Mean values of coding

Thiazide 2.94

Thiazide and methyldopa 4.05

Thiazide, methyldopa, and hydralazine 4.95

Propranolol 3.10

Propranolol and thiazide 2.53

Brinerdine 3.20

Minizide 1.30

Effectiveness score/ average monthly cost

Thiazide 0.49

Thiazide and methyldopa 0.27

Thiazide,mMethyldopa, and hydralazine 0.18

Propranolol 0.26

Propranolol and thiazide 0.14

Brinerdine 0.21

Minizide 0.06

See comparison result

Modeling

Assumed the use of β-blockers reduced the risk of non-fatal CVD events from 7.7% to 4% and risk of death from 8.2% to 4.2% but increased the risk of adverse events from 33.8% to 49.2% Assumed the use of statins reduced the risk of non-fatal CVD events from 11.3% to 6.5% and risk of death from 4% to 2.2%

Peri-operative β-blocker therapy may potentially save R869 per patient, statin treatment R1,822 per patient

Not reported

Modeling

Assumed a 19.8% 30-day event (MI, recurrent angina, or death) rate for those using enoxaparin and a 23.3% 30-day event rate for those using UFH

Cost/patient of enoxaparin = Z1085; cost/patient of UFH = Z1097

See comparison result

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/Setting

Intervention

Comparator

Araujo et al., 2008

Brazil

Pre-hospital thrombolysis in acute MI

In-hospital

 

Rodriguez et al., 1993

Argentina

Percutaneous transluminal coronary angioplasty (PTCA)

Coronary artery bypass graft (CABG) surgery

 

Grines et al., 1998

Multi-national: (developed and developing nations)

Early discharge after primary angioplasty in low-risk patients after acute MI

Traditional Care

Health Care Delivery

 

 

 

 

 

Diaz et al., 2006

Chile

Stroke unit

Regular hospital care

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Modeling

Assumed a gain of .1585 life years over 20 years with use of pre-hospital thrombolysis versus in-hospital thrombolysis

Dominated Pre-hospital thrombolysis cost R$176 less per .1585 life year gained (over 20 years)

See comparison result

RCT

In-hospital complication rate for PTCA was death 1.5%, AMI 6.3%, emergency CABG 1.5%, and stroke 1.5% In-hospital complication rate for CABG was death 4.6%, AMI 6.2%, emergency PTCA 1.5%, stroke 3.1%

Cumulative (group) costs at 1-year: PTCA (US$438,000), CABG (US$828,000)

Not reported

RCT

Rates of readmission in early discharge patients were 4.2% for recurrent unstable ischemia or MI, target vessel revascularization 9.8%, death 0.8%, reinfarction 0.8%, unstable ischemia 10.1%, stoke 0.4%, CHF 4.6%, and any event 15.2%

Rates of readmission in traditional care patients were 3.9% for recurrent unstable ischemia or MI, target vessel revascularization 8.6%, death 0.4%, reinfarction 0.4%, unstable ischemia 12.0%, stroke 2.6%, CHF 4.3%, and any event 17.5%

Early discharge patients had significantly lower hospital costs (US$9,658 +/–5,287) compared to traditional care (US$11,604 +/–6,125)

Not reported

Observational trial

Stroke unit: Mean length of stay: 6.6 days

Hospital: Mean length of stay: 9.9 days

Stroke unit: Mean cost per patient: US$5.550;

Hospital: Mean cost per patient US$4.815

Not reported

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Intervention Type

Reference

Country/Setting

Intervention

Comparator

Pannarunothai et al., 2001

Thailand

Health care delivery by urban health center for hypertension and diabetes

Healthcare delivery by home visit program at the regional hospital and no home visit program

 

Hauswald and Yeoh, 1997

Malaysia

EMS system to treat acute MI

Current care (performed by police/ private vehicle)

NOTE: ACE-inhibitor = Angiotensin converting enzyme inhibitor; AMI = Acute Myocardial Infarction; CABG = Coronary Artery Bypass Graft; CBV = Cerebrovascular; CER = Cost-Effectiveness Ratio; CHD = Coronary Heart Disease; CHF = Congestive Heart Failure; CVD = Cardiovascular Disease; DALY = Disability-Adjusted Life Year; GDP = Gross Domestic Product; GNI = Gross National Income; ICER = Incremental Cost-Effectiveness Ratio; MI = Myocardial Infarction; PTCA = Percutaneous Transluminal Coronary Angioplasty; QALY = Quality-Adjusted Life Year; RCT = Randomized Controlled Trial; SBP = Systolic Blood Pressure; SDBP = Sitting Diastolic Blood Pressure; UFH = Unfractionated Heparin; WHO = World Health Organization.

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

Methodologya

Outcome or Assumed Outcomea

Economic Analysis Resulta

Cost-Effective?

Retrospective analysis

Identified the % of patients with controlled hypertension (SBP <160mmHg) was 79.4% at the urban health center, 72.8% at the Maharaj Hospital, and 79.8% of people receiving no home visit care

Total costs per % of patients with controlled disease

See comparison result

 

Hypertension:

Urban health center 5729 baht

Maharaj Hospital home visit 7137 baht

No home visit 7195 baht

 

 

Identified the % of patients with controlled diabetes (fasting blood sugar 80-140mg/dl) was 50% at the urban health center, 49% at the Maharaj Hospital, and 33% of people receiving no home visit care

 

 

Diabetes:

Urban health center 7468 baht

Maharaj Hospital home visit 12313 baht

No home visit 17861baht

 

Modeling

Assumed delivery of a defibrillator to 85% of patients in less than 6 minutes and a 6% increase in survival rate from pre-hospital defibrillation with 50% having significant neurologic injury

Pre-hospital system for Kuala Lumpur would cost approximately US$357,000 per life saved with approximately 40% having significant neurological damage

Not reported

Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
×

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Amira, O., and N. Okubadejo. 2007. Frequency of complementary and alternative medicine utilization in hypertensive patients attending an urban tertiary care centre in Nigeria. BMC Complementary and Alternative Medicine 7(1):30.

Anderson, A. N., F. Wessels, I. Moodley, and K. Kropman. 2000. At1 receptor blockers—cost-effectiveness within the South African context. South African Medical Journal 90(5):494-498.

Araujo, D. V., B. R. Tura, A. L. Brasileiro, H. Luz Neto, A. L. Pavao, and V. Teich. 2008. Cost-2008. Cost-effectiveness of prehospital versus inhospital thrombolysis in acute myocardial infarction. Arquivos Brasileiros de Cardiologia 90(2):91-98.

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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Suggested Citation:"7 Making Choices to Reduce the Burden of Cardiovascular Disease." Institute of Medicine. 2010. Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health. Washington, DC: The National Academies Press. doi: 10.17226/12815.
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Cardiovascular disease (CVD), once thought to be confined primarily to industrialized nations, has emerged as a major health threat in developing countries. Cardiovascular disease now accounts for nearly 30 percent of deaths in low and middle income countries each year, and is accompanied by significant economic repercussions. Yet most governments, global health institutions, and development agencies have largely overlooked CVD as they have invested in health in developing countries. Recognizing the gap between the compelling evidence of the global CVD burden and the investment needed to prevent and control CVD, the National Heart, Lung, and Blood Institute (NHLBI) turned to the IOM for advice on how to catalyze change.

In this report, the IOM recommends that the NHLBI, development agencies, nongovernmental organizations, and governments work toward two essential goals:

  • creating environments that promote heart healthy lifestyle choices and help reduce the risk of chronic diseases, and
  • building public health infrastructure and health systems with the capacity to implement programs that will effectively detect and reduce risk and manage CVD.

To meet these goals, the IOM recommends several steps, including improving cooperation and collaboration; implementing effective and feasible strategies; and informing efforts through research and health surveillance. Without better efforts to promote cardiovascular health, global health as a whole will be undermined.

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