Cost-effectiveness of medical primary prevention strategies to reduce absolute risk of cardiovascular disease in Tanzania: a Markov modelling study.

Ole F. Norheim,Frida N. Ngalesoni,Amani T. Mori,Bjarne Robberstad,George M. Ruhago

doi:10.1186/s12913-016-1409-3

Abstract

BackgroundCardiovascular disease (CVD) is a growing cause of mortality and morbidity in Tanzania, but contextualized evidence on cost-effective medical strategies to prevent it is scarce. We aim to perform a cost-effectiveness analysis of medical interventions for primary prevention of CVD using the World Health Organization’s (WHO) absolute risk approach for four risk levels.MethodsThe cost-effectiveness analysis was performed from a societal perspective using two Markov decision models: CVD risk without diabetes and CVD risk with diabetes. Primary provider and patient costs were estimated using the ingredients approach and step-down methodologies. Epidemiological data and efficacy inputs were derived from systematic reviews and meta-analyses. We used disability- adjusted life years (DALYs) averted as the outcome measure. Sensitivity analyses were conducted to evaluate the robustness of the model results.ResultsFor CVD low-risk patients without diabetes, medical management is not cost-effective unless willingness to pay (WTP) is higher than US$1327 per DALY averted. For moderate-risk patients, WTP must exceed US$164 per DALY before a combination of angiotensin converting enzyme inhibitor (ACEI) and diuretic (Diu) becomes cost-effective, while for high-risk and very high-risk patients the thresholds are US$349 (ACEI, calcium channel blocker (CCB) and Diu) and US$498 per DALY (ACEI, CCB, Diu and Aspirin (ASA)) respectively. For patients with CVD risk with diabetes, a combination of sulfonylureas (Sulf), ACEI and CCB for low and moderate risk (incremental cost-effectiveness ratio (ICER) US$608 and US$115 per DALY respectively), is the most cost-effective, while adding biguanide (Big) to this combination yielded the most favourable ICERs of US$309 and US$350 per DALY for high and very high risk respectively. For the latter, ASA is also part of the combination.ConclusionsMedical preventive cardiology is very cost-effective for all risk levels except low CVD risk. Budget impact analyses and distributional concerns should be considered further to assess governments’ ability and to whom these benefits will accrue.

Highlights

Cardiovascular disease (CVD) is a growing cause of mortality and morbidity in Tanzania, but contextualized evidence on cost-effective medical strategies to prevent it is scarce
CVD risk Low risk The results suggest that providing a combination of angiotensin converting enzyme inhibitor (ACEI) and Diu averts 0.41 disability- adjusted life years (DALY) at a cost of United States of America dollar (US$)544 compared to no treatment, yielding the lowest incremental cost-effectiveness ratio (ICER) of US$1327 per DALY averted
For very high-risk patients, soluble aspirin (ASA) was part of the combination. These conclusions are in line with the World Health Organization (WHO)’s CVD preventive guidelines, which recommend no medical management for low CVD risks [22]

Summary

Introduction

Cardiovascular disease (CVD) is a growing cause of mortality and morbidity in Tanzania, but contextualized evidence on cost-effective medical strategies to prevent it is scarce. A decade later there had been a 15 % increase in the percentage of total DALYs lost attributed to these conditions [1]. Costs ascribed to CVD are substantial; for example, in 2010, they amounted to about US$11.6 billion in the World Health Organization’s (WHO) African region E (AFRO E). These costs are expected to rise by 22 % by 2030 [2].

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