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Generalized cost-effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina |
Rubinstein A, Garcia Marti S, Souto A, Ferrante D, Augustovski F |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the cost-effectiveness of interventions to decrease cardiovascular disease. Lowering salt intake, mass media health education, and a polypill for people with a 20% or greater risk were the most cost-effective strategies in Argentina. Smoking cessation and treatment of hypercholesterolaemia and hypertension were not cost-effective. The study was based on valid methodology, but the validity of the authors’ conclusions might have been affected by the limited reporting of the clinical data, and the restricted use of sensitivity analysis. Type of economic evaluation Study objective This study examined the cost-effectiveness of various individual and population-based interventions to reduce cardiovascular disease (CVD). Interventions Six individual and two population-based interventions, all of which were implemented for 10 years, were compared with no intervention. The individual interventions, which were assumed to be delivered to the uninsured population in Buenos Aires (26.5% of total population), were:
treatment of hypertension through lifestyle change and drugs; treatment of hypercholesterolaemia through a low-cholesterol diet and statins; smoking cessation by drug therapy with bupropion for two months; modified polypill strategy (thiazides 25mg, enalapril 10mg, atorvastatin 10mg, and aspirin 100mg) for individuals with an estimated combined risk of cardiovascular events over the next decade above 5%; modified polypill strategy for those with a risk above 10%; and modified polypill strategy for those with a risk above 20%.
The two population-based interventions were: cooperation between government, consumer association, and bakery chambers to reduce salt in bread (a reduction of 1g of salt per 100g of bread); and mass education strategies to reduce hypertension, hypercholesterolaemia, and obesity. Location/setting Argentina/primary care and community. Methods Analytical approach:An analytic model based on the World Health Organization's CHOosing Interventions that are Cost Effective (WHO-CHOICE) methodology was developed to examine the costs and benefits of the preventive strategies. The time horizon of the analysis was 100 years. The authors stated that the analysis was carried out from the perspective of the public health sector, specifically that of the City of Buenos Aires.
Effectiveness data:The clinical data came from systematic reviews of randomised controlled trials (RCTs) and meta-analyses, when possible. Specific details on the individual sources of data or on pooling methods were not given. The primary endpoint was the relative risk reduction for stroke and CVD for each of the interventions compared with no intervention.
Monetary benefit and utility valuations:The disability weights for CVD and stroke were derived from the WHO-CHOICE CVD template, which was based on Framingham data. No other details were given.
Measure of benefit:Disability-adjusted life-years (DALYs) were the summary benefit measure and were discounted at an annual rate of 3%. The DALYs were age-weighted.
Cost data:The economic analysis considered two broad cost categories: programme-level expenses associated with the implementation of the intervention (administration, training, and information dissemination); and patient-level data (primary care visits, ancillary tests, and drugs). The future costs of disease averted were not included. The quantities of resources used were based on published data and supplemented with expert opinions. The costs came from similar programmes carried out in the City of Buenos Aires, or from expert opinions. Drug costs were calculated using a mixture of those for blood pressure lowering agents and data from the database of the Health Ministry of Buenos Aires. All costs were in Argentine pesos (ARS). Future costs were discounted at an annual rate of 3% and the price year was 2005.
Analysis of uncertainty:One-way sensitivity analyses were carried out to assess the impact of variations in some baseline risk levels and effect size for the interventions. An arbitrary range of ± 20% was used. In alternative scenarios, undiscounted costs and benefits were considered, and non age-weighted DALYs were calculated. Results The total costs were ARS 87,471 with less salt in bread; ARS 634,069 with mass media campaign; ARS 23,533,467 with polypill for over 20% CVD risk; ARS 46,323,335 with polypill for over 10% CVD risk; ARS 63,893,600 with polypill for over 5% CVD risk; ARS 37,478,853 with blood pressure lowering therapy; ARS 12,317,628 with smoking cessation therapy; and ARS 40,253,626 with treatment for hypercolesterolaemia.
The DALYs were 579 with less salt in bread; 1,158 with mass media campaign; 6,539 with polypill for over 20% CVD risk; 11,263 with polypill for over 10% CVD risk; 14,095 with polypill for over 5% CVD risk; 4,857 with blood pressure lowering therapy; 367 with smoking cessation therapy; and 567 with treatment of hypercolesterolaemia.
The average cost-utility ratios (or incremental costs per DALY over no intervention) were ARS 151 with less salt; ARS 547 with mass media; ARS 3,599 with polypill over 20%; ARS 4,113 with polypill over 10%; ARS 4,533 with polypill over 5%; ARS 7,716 with blood pressure therapy; ARS 33,563 with smoking cessation; and ARS 70,994 with hypercholesterolaemia treatment.
Considering the threshold of average per capita income in Argentina, the most cost-effective interventions were lowering salt in bread, health education through a mass media campaign, and the polypill strategy targeting people with a 20% or greater risk of CVD.
The sensitivity analysis did not substantially alter the base-case findings. Authors' conclusions The authors concluded that lowering salt intake, health education through a mass media campaign, and the polypill strategy targeting people with a 20% or greater risk were the most cost-effective interventions from the perspective of the public payer in Argentina. CRD commentary Interventions:A clear description of each intervention was given. The selection of these strategies was appropriate as all the relevant comparators appear to have been considered.
Effectiveness/benefits:The authors provided little information on the search strategy used to identify the sources of data. It was stated that most data came from RCTs or meta-analyses, which are generally valid sources of clinical data. Although the methodology followed WHO guidelines, the provision of more information on the derivation of the clinical inputs and disability weights would have been useful to allow a comprehensive judgement of the validity of these estimates. DALYs are a validated benefit measure, strongly recommended in WHO publications for health care interventions in developing countries.
Costs:The authors explicitly reported the perspective and most of the relevant costs appear to have been included. It was not clear why future costs avoided due to a reduction of CVD or stroke events were not included. This could have had a big impact on the cost-effectiveness ratios. The costs were presented as macro-categories and a detailed breakdown of cost items was not given. The sources of data were reported. Cost estimates were treated deterministically and the impact of variations in cost estimates was not investigated in the sensitivity analysis. The price year and the use of discounting were reported and undiscounted costs were also presented.
Analysis and results:The costs and benefits were synthesised using average ratios, but the use of an incremental approach comparing the selected interventions would have been more appropriate. The cost-effectiveness of each programme was tested against a threshold based on the average per capita income, as recommended in WHO guidelines. A budget impact analysis was also carried out. The issue of uncertainty was restricted to a few inputs to the model rather than a global assessment. The authors compared their results with those from other published studies, which were similar.
Concluding remarks:The study was based on valid methodology, although the clinical side of the analysis was not extensively reported, and the investigation of uncertainty was limited. These issues might affect the validity of the authors’ conclusions. Funding Funded by the Program of Epidemiological Surveillance (VIGI+A), Ministry of Health, Argentina; and Secretary of Health, Buenos Aires, Argentina. Bibliographic details Rubinstein A, Garcia Marti S, Souto A, Ferrante D, Augustovski F. Generalized cost-effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina. Cost Effectiveness and Resource Allocation 2009; 7: 10 Other publications of related interest Murray CJ, Lauer JA, Hutubessy RC, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular disease risk. Lancet 2003;361:717-25.
Asaria P, Chisholm D, Mathers C, et al. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 2007;370:2044-53.
Abegunde DO, Mathers CD, Adam T, et al. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007;370:1929-38. Indexing Status Subject indexing assigned by CRD MeSH Argentina; Cardiovascular Diseases; Cost-Benefit Analysis; Health Promotion; Humans; Hypercholesterolemia /therapy; Hypertension /therapy; Mass Media; Smoking Cessation AccessionNumber 22009102071 Date bibliographic record published 23/09/2009 Date abstract record published 21/10/2009 |
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