A Cost-Effectiveness Tool to Guide the Prioritization of Interventions for Rheumatic Fever and Rheumatic Heart Disease Control in African Nations.

Bongani Mayosi,David Watkins,Solomon J Lubinga,Joseph B Babigumira,Gary L Simon

doi:10.1371/journal.pntd.0004860

Abstract

BackgroundRheumatic heart disease (RHD) prevalence and mortality rates remain especially high in many parts of Africa. While effective prevention and treatment exist, coverage rates of the various interventions are low. Little is known about the comparative cost-effectiveness of different RHD interventions in limited resource settings. We developed an economic evaluation tool to assist ministries of health in allocating resources and planning RHD control programs.Methodology/Principal FindingsWe constructed a Markov model of the natural history of acute rheumatic fever (ARF) and RHD, taking transition probabilities and intervention effectiveness data from previously published studies and expert opinion. Our model estimates the incremental cost-effectiveness of scaling up coverage of primary prevention (PP), secondary prevention (SP) and heart valve surgery (VS) interventions for RHD. We take a healthcare system perspective on costs and measure outcomes as disability-adjusted life-years (DALYs), discounting both at 3%. Univariate and probabilistic sensitivity analyses are also built into the modeling tool. We illustrate the use of this model in a hypothetical low-income African country, drawing on available disease burden and cost data. We found that, in our hypothetical country, PP would be cost saving and SP would be very cost-effective. International referral for VS (e.g., to a country like India that has existing surgical capacity) would be cost-effective, but building in-country VS services would not be cost-effective at typical low-income country thresholds.Conclusions/SignificanceOur cost-effectiveness analysis tool is designed to inform priorities for ARF/RHD control programs in Africa at the national or subnational level. In contrast to previous literature, our preliminary findings suggest PP could be the most efficient and cheapest approach in poor countries. We provide our model for public use in the form of a Supplementary File. Our research has immediate policy relevance and calls for renewed efforts to scale up RHD prevention.

Highlights

Decision-makers in African countries face difficult tradeoffs when choosing among interventions that address acute rheumatic fever (ARF) and its sequel rheumatic heart disease (RHD)
Rheumatic heart disease is a major cause of cardiovascular morbidity and mortality in Africa
Our study describes the methods and data we used to develop a cost-effectiveness analysis tool that was intended for decision-making in African countries

Summary

Introduction

Decision-makers in African countries face difficult tradeoffs when choosing among interventions that address acute rheumatic fever (ARF) and its sequel rheumatic heart disease (RHD). There is evidence that ARF and RHD can be eradicated in both high-income and limited resource settings.[1,2,3] Yet these conditions remain neglected by the global health community. [4] Further, the prevalence of RHD appears to be increasing, and mortality rates in Africa are among the highest in the world.[4,5]. Rheumatic heart disease (RHD) prevalence and mortality rates remain especially high in many parts of Africa. Little is known about the comparative cost-effectiveness of different RHD interventions in limited resource settings. We developed an economic evaluation tool to assist ministries of health in allocating resources and planning RHD control programs

Results

Discussion

Conclusion