Cardiovascular Disease Policy Model Research Articles

Cost-effectiveness of semaglutide for secondary prevention of cardiovascular disease in the United States

Abstract Background In the SELECT trial, semaglutide produced a 20% reduction in the composite of cardiovascular death, non-fatal myocardial infarction (MI), and non-fatal stroke in individuals with overweight or obesity who did not have diabetes but had established pre-existing cardiovascular disease (CVD). Cost is an important barrier to widespread uptake of semaglutide, particularly in the US, and the cost-effectiveness for the secondary prevention of CVD is uncertain. Purpose To evaluate the cost-effectiveness of semaglutide vs. no obesity treatment for the secondary prevention of CVD from a US healthcare sector perspective. Methods The CVD Policy Model is an established, validated simulation model of fatal and non-fatal CVD outcomes and costs in the US population. Using data from the National Health and Nutrition Examination Survey, we created a nationally representative cohort of SELECT-eligible individuals (age ≥45, BMI ≥27kg/m2, no diabetes, pre-existing CVD). Healthcare costs associated with acute and chronic CVD were estimated from national survey and claims data and inflated to 2023 US dollars. The simulated control arm received usual care; the intervention arm received weekly semaglutide 2.4mg injections (assuming 8% discontinuation, which occurs year one). We reproduced the effectiveness of semaglutide based on results of the SELECT trial primary cardiovascular composite endpoint (non-fatal MI, non-fatal strokes and CVD death). The base case assumed 7% of patients receiving semaglutide developed injection-site reactions. Monthly cost of semaglutide was assumed to be $717 (US price net of rebates and discounts), but this was varied in sensitivity analyses. The analysis adopted a health system perspective over lifetime horizon. Results Approximately 4.7 million US adults would meet SELECT trial eligibility criteria. Over a lifetime horizon, semaglutide is projected to avert 538,000 major adverse cardiovascular events (241,000 nonfatal MIs; 80,000 nonfatal stokes, and 217,000 cardiovascular deaths) at an incremental cost of $613 billion. The incremental cost effectiveness ratio for semaglutide was $443,000 per quality-adjusted life year (QALY) gained. In order to meet cost-effectiveness thresholds of $50,000/QALY, $100,000/QALY, $150,000/QALY, drug costs would have to decline 90%, 79%, and 69% respectively. In sensitivity analyses, lowering drug cost to the current UK price (~ $220 per patient per month) would improve the incremental cost-effectiveness of semaglutide to <$150,000 per QALY gained, a potential upper threshold for cost-effectiveness in the US. Conclusion Widespread uptake of semaglutide in the SELECT-eligible U.S. population would prevent a large number of cardiovascular events, but its use would be low economic value at current US prices. Lowering prices in line with those in Europe (e.g., monthly price from $717 to $223) would make the therapy cost-effective at a threshold of $150,000 per QALY gained.

Abstract P162: Projected Reduction in Incident Non-Ischemic Heart Failure by Controlling Risk Factors in Individuals With Diabetes

Background: Individuals with diabetes have an elevated risk of non-ischemic heart failure (NIHF), and comorbidities such as hypertension, obesity, and smoking exacerbate this risk. Compared with the status quo in US adults with diabetes, we projected the decrease in NIHF incidence and prevalence that could occur if hypertension, overweight/obesity, and smoking status were treated to evidence-based thresholds. Methods: The Cardiovascular Disease (CVD) Policy Model is a computer simulation that provides nationally representative estimates of CVD burden for the US population aged 35-94 years. We used National Health and Nutrition Examination Survey (2015-2018) data to determine diabetes prevalence (i.e., “ever been told you have diabetes”, HbA1c ≥6.5%, fasting glucose ≥126mg/dl, or non-fasting glucose ≥200mg/dl) in individuals without prior CVD. Incident NIHF rates were estimated from pooled epidemiologic cohorts. We modeled the impact of treating hypertension (SBP ≥130mmHg), overweight or obesity (BMI ≥25Kg/m 2 ), and current smoking to evidence-based thresholds (SBP <130mmHg, BMI <25Kg/m 2 , and smoking cessation) on incident and prevalent NIHF over ten years (2023-2032). Results: An estimated 28.4 million US adults aged 35-94 years have diabetes and no prior CVD. Of these, 50% have hypertension, 89% are overweight or obese, and 13% are current smokers. In ten years under the status quo, the projected incidence of NIHF would be 604,000 cases per year and the prevalence of NIHF would be 4.7 million individuals. Treating risk factors to evidence-based thresholds across the whole population would reduce NIHF incidence to 528,000 cases per year, a 13% decline, and prevalence to 4.4 million individuals, an 8% decline. Achieving a BMI ≤25Kg/m 2 among those with overweight/obesity would have the greatest independent effect on projected HF incidence and prevalence ( Table ). Conclusions: Weight loss, blood pressure control, and smoking cessation in patients with diabetes could substantially reduce the US burden of incident NIHF.

Abstract MP06: Cardiovascular Disease in Community-Dwelling US Adults Involved With the Criminal Justice System: A Simulation Analysis

Introduction: Approximately 4.4 million US adults live in the community while on probation or parole. They have disproportionately elevated cardiovascular risk factors, morbidity and mortality, along with limited access to healthcare. However, the long-term burden of cardiovascular disease (CVD) in this population is uncertain. We developed a simulation model to quantify cardiovascular risk and adverse events in community-dwelling US adults involved with the criminal justice system, leveraging all known sources of data on this under-studied, high-risk population. Methods: We adapted the CVD Policy Model, a validated state-transition simulation model of CVD in all US adults, using input data specific to 25-54 year-old individuals on probation or parole in 2018. Population size was defined using estimates from the Bureau of Justice Statistics. CVD risk factor burden was approximated by re-weighting data from the National Health and Nutrition Examination Survey years 2005 to 2018 to match demographic, socioeconomic, and health variables among individuals reporting past-year probation or parole in the National Survey on Drug Use and Health. CVD incidence and mortality rates were calibrated to outcomes in cohort studies and vital statistics data. Outcomes were myocardial infarction (MI), stroke, and death over a 10-year horizon (2018-2027) and were compared with projections for an age- and gender-matched cohort of adults in the general US population. We also examined projected reductions in CVD outcomes over 10 years that could be expected if risk factor distributions in the probation/parole population were similar to distributions observed for the general US population. Results: The simulated cohort consisted of 2.9 million adults 25-54 years of age on probation or parole in 2018; 71% were men, 30% were living below the poverty line, and 57% had no regular access to healthcare. An estimated 61% were current smokers, 29% had BP ≥130/80 mmHg, and 8% had diabetes. The study cohort was projected to experience between 36,400 and 69,600 incident MIs and between 22,400 and 37,500 incident strokes over 10 years. This would be 1.4-2.6 times the CVD incidence in age- and gender-matched adults in the general US population. Lowering rates of active smoking in those on probation or parole to rates observed for the general US population (i.e., from 61% to 21%) would reduce MI and stroke events by 16,400 to 29,100 over 10 years, a 27% reduction from current projections. Discussion: We developed and calibrated a computer simulation model to quantify the burden of CVD in community-dwelling US adults followed by the US justice system. We project that adults on probation or parole have higher CVD risk than the general US population. Future work will leverage this platform to estimate the impact of clinical, community, and policy interventions to reduce CVD burden in this vulnerable population.

Familial Hypercholesterolemia Variant and Cardiovascular Risk in Individuals With Elevated Cholesterol

Familial hypercholesterolemia (FH) is a genetic disorder that often results in severely high low-density lipoprotein cholesterol (LDL-C) and high risk of premature coronary heart disease (CHD). However, the impact of FH variants on CHD risk among individuals with moderately elevated LDL-C is not well quantified. To assess CHD risk associated with FH variants among individuals with moderately (130-189 mg/dL) and severely (≥190 mg/dL) elevated LDL-C and to quantify excess CHD deaths attributable to FH variants in US adults. A total of 21 426 individuals without preexisting CHD from 6 US cohort studies (Atherosclerosis Risk in Communities study, Coronary Artery Risk Development in Young Adults study, Cardiovascular Health Study, Framingham Heart Study Offspring cohort, Jackson Heart Study, and Multi-Ethnic Study of Atherosclerosis) were included, 63 of whom had an FH variant. Data were collected from 1971 to 2018, and the median (IQR) follow-up was 18 (13-28) years. Data were analyzed from March to May 2023. LDL-C, cumulative past LDL-C, FH variant status. Cox proportional hazards models estimated associations between FH variants and incident CHD. The Cardiovascular Disease Policy Model projected excess CHD deaths associated with FH variants in US adults. Of the 21 426 individuals without preexisting CHD (mean [SD] age 52.1 [15.5] years; 12 041 [56.2%] female), an FH variant was found in 22 individuals with moderately elevated LDL-C (0.3%) and in 33 individuals with severely elevated LDL-C (2.5%). The adjusted hazard ratios for incident CHD comparing those with and without FH variants were 2.9 (95% CI, 1.4-6.0) and 2.6 (95% CI, 1.4-4.9) among individuals with moderately and severely elevated LDL-C, respectively. The association between FH variants and CHD was slightly attenuated when further adjusting for baseline LDL-C level, whereas the association was no longer statistically significant after adjusting for cumulative past LDL-C exposure. Among US adults 20 years and older with no history of CHD and LDL-C 130 mg/dL or higher, more than 417 000 carry an FH variant and were projected to experience more than 12 000 excess CHD deaths in those with moderately elevated LDL-C and 15 000 in those with severely elevated LDL-C compared with individuals without an FH variant. In this pooled cohort study, the presence of FH variants was associated with a 2-fold higher CHD risk, even when LDL-C was only moderately elevated. The increased CHD risk appeared to be largely explained by the higher cumulative LDL-C exposure in individuals with an FH variant compared to those without. Further research is needed to assess the value of adding genetic testing to traditional phenotypic FH screening.

Abstract 17197: Team-Based Care for Uncontrolled Hypertension in Accountable Care Organizations: A Simulation Study

Background and Objectives: Team-based care (TBC) is associated with greater blood pressure (BP) reductions than usual care, particularly when non-physicians titrate antihypertensive medications, but has yet to be widely adopted. This analysis projected the effectiveness of TBC among patients with uncontrolled hypertension from three accountable care organizations (ACOs): Columbia University Medical Center (New York), Cedars-Sinai Medical Center (California), and Ochsner Accountable Care Network (Louisiana). Methods: The Cardiovascular Disease (CVD) Policy Model is a computer model that simulates modifiable hypertension care processes (i.e., office visit frequency, BP measurement accuracy, medication intensification, and patient medication adherence) and has been validated to reproduce TBC outcomes. We used the CVD Policy Model to simulate the ACO population aged >=65 years with BP >=140/90 mmHg at two outpatient visits in 2015, and project BP and CVD outcomes out to 10 years with usual care alone vs. one year of TBC followed by a return to usual care. Hypertension usual care processes were derived from national sources and published literature. The model was calibrated to reproduce systolic BP reductions with TBC at one year vs. usual care from a published meta-analysis, which were stratified by the team member responsible for antihypertensive medication titration: -5.0 (95%CI -7.9, -2.2) mmHg with physician titration and -10.5 (95%CI -16.2, -4.8) mmHg with non-physician titration. Results: The ACO population with uncontrolled BP (N=9,788) had a mean (SD) age of 76.3 (7.8) years; 66.6% were white and 59.8% female. The mean BP (SD) at baseline was 151.1 (13.0)/78.1 (10.6) mmHg and 39.1% had a history of CVD. Compared with usual care at 10 years, TBC with non-physician titration was projected to increase the proportion with BP <140/90 mmHg by 16.0% and TBC with physician titration by 4.2%. Relative to usual care, TBC with non-physician titration was projected to prevent 20.8 CVD events per 1000 individuals and TBC with physician titration to prevent 6.6 CVD events. Conclusion: Universal adoption of TBC, especially with non-physician titration, could improve achievement of quality benchmark BP control goals and prevent CVD events in ACO populations.

Abstract 15469: Projected Heart Failure Incidence in US Adults From 2018-2050

Background Heart failure (HF) currently affects 6.7 million people in the US accounting for $40 billion in annual healthcare costs. Projecting future trends in the clinical burden of HF may guide strategic investments in prevention and treatment as well as workforce planning. This study projects the incidence of heart failure in the US population through 2050. Methods: The Cardiovascular Disease (CVD) Policy Model is an established computer-simulation, state-transition model for the US population ages 35-94 years. Age- and sex- specific HF incidence rates were derived from NHLBI pooled cohort studies; the probability of HF hospitalizations associated with coronary heart disease (CHD) or stroke were derived from the National Inpatient Sample and published literature. We applied age- and sex-specific risk factor distributions, incidence, and event rates from 2018 to population projections through 2050 from the US Census. The model estimated absolute number of incident HF cases in subpopulations with CHD (ischemic HF) and without CHD (non-ischemic HF). Results: In 2018, 11% of the US population without HF was aged >=75 years, which compares with 16% projected in 2050. The estimated HF incidence rate was higher in males. The annual incidence of HF in US adults aged 35 to 94 years is projected to increase by 39% from 836,000 in 2018 to 1.2 million by 2050 (Table 1). Most incident HF is estimated to occur in the population without CHD, accounting for three quarters of HF in women and over half in men. Among those with HF, the proportion of the population aged >=75 years was projected to increase from 42% in 2018 to 54% in 2050. Conclusion A large increase in incident HF is expected in coming years, primarily due to an aging population. Most incident HF is estimated to be non-ischemic. Primary prevention, specifically controlling risk factors associated with non-ischemic HF, may offer the greatest opportunity to reduce HF incidence.

Abstract 15672: Cost-Effectiveness of Team-Based Care for Hypertension

Introduction: Team-based care (TBC), typically involving a physician and non-physician working in collaboration, is more effective than usual physician-only care in reducing blood pressure (BP). This analysis estimated the cost-effectiveness of TBC strategies vs. usual care over 10 years. Methods: We used the Cardiovascular Disease (CVD) Policy Model to project long-term BP, CVD events, and survival in a nationally representative cohort of 10,000 US adults (aged ≥20 years) with uncontrolled BP (≥140/90 mmHg) from the National Health and Nutrition Examination Survey. We compared (1) usual care, (2) TBC with a registered nurse providing hypertension counseling, and (3) TBC with a pharmacist providing counseling and titrating medications. BP reductions with TBC were derived from meta-analysis; other inputs were derived from published literature and publicly available data. TBC interventions were simulated to last six months, after which individuals were assumed to return to usual care. The outcomes were mean per-patient direct healthcare costs (2021 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) from a US healthcare sector perspective. Sensitivity analyses assessed the impact of TBC program design and hypertension care process parameters on the cost-effectiveness of TBC. Results: The mean (SD) age was 59.8 (16.6) years, 50.0% were female, and mean baseline systolic BP was 150.9 (14.2) mmHg. At 10 years, TBC with nurse counseling and with pharmacist titration were projected to result in mean (95% uncertainty interval) 0.6-mmHg (0.4, 0.8) and 2.8-mmHg (2.2, 3.4) greater reductions in systolic BP. Both TBC strategies were estimated to dominate (i.e., cost less and more effective) usual care, with nurse counseling projected to cost -$617 (-$1539, $364) and with pharmacist titration -$416 (-$1400, $470) less than usual care. Compared with TBC with nurse counseling, TBC with pharmacist titration had an ICER of $13,000/QALY gained (88.0% probability ICER <$50,000/QALY gained). The ICER was most sensitive to the probability of pharmacist medication intensification. Conclusions: TBC with pharmacist titration is a cost-effective strategy to reduce CVD events in US adults with uncontrolled hypertension.

Abstract 137: Projected Impact Of Non-pharmacologic Management Of Stage 1 Hypertension Among Lower-risk U.s Adults

Introduction: The 2017 ACC/AHA guidelines lowered the diagnostic blood pressure (BP) threshold, resulting in a new hypertension diagnosis for millions of younger, lower-risk U.S adults. Clinicians are encouraged to counsel these patients on health behavior modification. However, the potential population-level benefits from these non-pharmacologic interventions have not been assessed. Methods: We used the Cardiovascular Disease (CVD) Policy Model to simulate CVD events, mortality, and healthcare costs between 2018 and 2027. Simulations targeted US adults aged 35-64 years with untreated systolic BP 130-139 mmHg. Based on 2015-2018 NHANES estimates, we defined individuals as lower-risk based on not having diabetes, chronic kidney disease, or CVD and a predicted <10% 10-year CVD risk. Inputs for effects of dietary modification, sustained weight loss, physical activity, smoking cessation, and alcohol moderation on SBP were from published meta-analyses and trial data. Results: Of the estimated 8.7 million U.S. adults (50.6% women) aged 35-64 with lower-risk stage 1 hypertension, 5.5 million (61%) had regular healthcare access. Controlling BP to <130 mmHg in the full target population could prevent 27,000 CVD events, avoid 2800 deaths, and save an associated $16 million healthcare costs. We would see the largest benefit from adoption of the Dietary Approaches to Stop Hypertension (DASH) diet, with an estimated 16,000 CVD events prevented among men and 11,000 among women (Figure). Conclusion: Substantial health and economic benefits could result from widespread adoption of non-pharmacologic interventions in lower-risk U.S. adults with Stage 1 hypertension.

Abstract P308: Comparative Cost-effectiveness Of Hypertension Treatment Guidelines In US Adults

Introduction: The 2017 ACC/AHA guidelines lowered blood pressure (BP) thresholds for hypertension diagnosis and treatment compared to the 2003 JNC7. We compared cost-effectiveness of treating to ACC/AHA and JNC7 over 10 years in untreated hypertensive adults 35-84 years of age. Methods: The Cardiovascular Disease (CVD) Policy Model simulates CVD events, deaths, and costs in US adults. Inputs are estimated from national datasets, cohort studies, and literature. We simulated three treatment strategies: (1) no pharmacological treatment; (2) full JNC7; or (3) full ACC/AHA. Base-case analyses targeted all treatment-eligible adults. Secondary analyses stratified treatment by baseline BP (130-139/80-89 vs. ≥140/90 mmHg) and indicators of high CVD risk (diabetes, CKD, CVD, or 10-yr risk ≥10%). Results: Twenty-four million untreated adults could be treated under JNC7 and 29 million under ACC/AHA, preventing 1.2 million and 1.5 million CVD events at 10 years, respectively. Treating to JNC7 compared to no treatment and ACC/AHA compared to JNC7 was cost-effective (<$50,000 per quality-adjusted life year gained) (Table). JNC7 or ACC/AHA was cost-saving for high-risk adults with BP ≥140/90 mmHg and cost-effective for high-risk adults with BP 130-139/80-89 mmHg (JNC7: $103,000/QALY; ACC/AHA: $90,000/QALY). Both JNC7 and ACC/AHA cost >$150,000 per QALY gained for treating lower risk adults. Conclusion: Treating according to either JNC7 or ACC/AHA guidelines is a cost-effective way to prevent CVD. At ten years, regardless of guideline, treating high-risk hypertensive patients is either cost-saving or cost-effective; treating lower-risk patients is relatively low value.

Cost-effectiveness of hypertension therapy based on 2020 International Society of Hypertension guidelines in Ethiopia from a societal perspective.

There is inadequate information on the cost-effectiveness of hypertension based on evidence-based guidelines. Therefore, this study was conducted to evaluate the cost-effectiveness of hypertension treatment based on 2020 International Society of Hypertension (ISH) guidelines from a societal perspective. We developed a state-transition Markov model based on the cardiovascular disease policy model adapted to the Sub-Saharan African perspective to simulate costs of treated and untreated hypertension and disability-adjusted life-years (DALYs) averted by treating previously untreated adults above 30 years from a societal perspective for a lifetime. The full implementation of the ISH 2020 hypertension guidelines can prevent approximately 22,348.66 total productive life-year losses annually. The incremental net monetary benefit of treating hypertension based was $128,520,077.61 US by considering a willingness-to-pay threshold of $50,000 US per DALY averted. The incremental cost-effectiveness ratio (ICER) of treating hypertension when compared with null was $1,125.44 US per DALY averted. Treating hypertension among adults aged 40-64 years was very cost-effective 625.27 USD per DALY averted. Treating hypertensive adults aged 40-64 years with diabetes and CKD is very cost-effective in both women and men (i.e., 559.48 USD and 905.40 USD/DALY averted respectively). The implementation of the ISH 2020 guidelines among hypertensive adults in Southern Ethiopia could result in $9,574,118.47 US economic savings. Controlling hypertension in all patients with or with diabetes and or CKD could be effective and cost-saving. Therefore, improving treatment coverage, blood pressure control rate, and adherence to treatment by involving all relevant stakeholders is critical to saving scarce health resources.

Cost-Effectiveness of Masked Hypertension Screening and Treatment in US Adults With Suspected Masked Hypertension: A Simulation Study.

BACKGROUNDRecent US blood pressure (BP) guidelines recommend using ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) to screen adults for masked hypertension. However, limited evidence exists of the expected long-term effects of screening for and treating masked hypertension.METHODSWe estimated the lifetime health and economic outcomes of screening for and treating masked hypertension using the Cardiovascular Disease (CVD) Policy Model, a validated microsimulation model. We simulated a cohort of 100,000 US adults aged ≥20 years with suspected masked hypertension (i.e., office BP 120–129/<80 mm Hg, not taking antihypertensive medications, without CVD history). We compared usual care only (i.e., no screening), usual care plus ABPM, and usual care plus HBPM. We projected total direct healthcare costs (2021 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios. Future costs and QALYs were discounted 3% annually. Secondary outcomes included CVD events and serious adverse events.RESULTSRelative to usual care, adding masked hypertension screening and treatment with ABPM and HBPM was projected to prevent 14.3 and 20.5 CVD events per 100,000 person-years, increase the proportion experiencing any treatment-related serious adverse events by 2.7 and 5.1 percentage points, and increase mean total costs by $1,076 and $1,046, respectively. Compared with usual care, adding ABPM was estimated to cost $85,164/QALY gained. HBPM resulted in lower QALYs than usual care due to increased treatment-related adverse events and pill-taking disutility.CONCLUSIONSThe results from our simulation study suggest screening with ABPM and treating masked hypertension is cost-effective in US adults with suspected masked hypertension.

Impacto sanitario de la prohibición total de publicidades de tabaco en argentina.

Health impact of the total ban on advertising of tobacco productsThe objective was to estimate the health impact of the total ban on advertising of tobacco products in terms of avoided cardiovascular events in those over 35 years of age in Argentina.The Cardiovascular Disease Policy Model (CVDPM) was used, which is a Markov simulation model used to represent and project mortality and morbidity due to cardiovascular disease (CVD) in the population aged 35 or over. It constitutes a demographic-epidemiological model, which represents the population between 35 and 95 years of age and uses a logistic regression model based on the Framingham equation to estimate the annual incidence of cardiovascular disease. We assumed that implementing a complete ban on the advertising of tobacco products would lead to a 9% reduction in tobacco consumption.The complete ban on advertising could prevent 15,164 deaths over a period of 10 years, of which 2610 would be the result of coronary heart disease and 747 due to stroke. These reductions would mean an annual decrease of 0.46% of total deaths, 0.60% of deaths from coronary heart disease and 0.33% in deaths from stroke. In addition, during the same period, it would avoid 6630 acute myocardial infarctions and 2851 strokes (reductions of 1.35% and 0.40%, respectively).We hope that these findings might contribute to the strengthening of sanitary tobacco control policies in Argentina based on the remarkable benefits of banning the advertising of tobacco products in full and in line with current global recommendations.

Abstract P113: Increasing Fruit And Vegetable Intake Prevents Incident Cardiovascular Disease And Cardiovascular Deaths

Background: Dietary intake of fruit and vegetables (FV) in the US falls well below recommended guidelines with only 12.2% of adults consuming at least 1.5-2 cup equivalents of fruit and 9.3% consuming at least 2-3 cup equivalents of vegetables each day. The Dietary Approaches to Stop Hypertension (DASH) trial demonstrated that consuming a “Mediterranean diet” with increased average daily FV intake resulted in reductions of systolic blood pressure of 0.8mmHg in those without hypertension and 7.2mmHg in those with hypertension. We used simulation modeling to estimate the impact of increasing FV intake in the population who currently are low FV consumers on subsequent incident cardiovascular disease (CVD) and death. Methods: We used the CVD Policy Model, a dynamic state-transition model of CVD risk factors, events, and outcomes to simulate the impact of increasing FV intake by one cup equivalent per day in US adults aged 35-94 years with no prior CVD who consume less than cup equivalent of FV per day; based on the National Health and Nutrition Examination Survey (NHANES) years 2015-2018. We used estimates of FV intake on blood pressure reductions based on DASH and ran 10 year simulations, focusing on the population with uncontrolled hypertension (baseline systolic BP ≥140mmHg). Results: Based on NHANES, 40.5M US adults age 35-94 years without a history of CVD consume less than 1 cup equivalent of FV per day. Increasing FV intake by cup equivalents per day in this population is estimated to prevent 98,000 incident CVD and 16,000 CVD deaths over 10 years, of which 82,000 (84%) and 13,000 (81%) respectively occur in 8.9M of this population with uncontrolled hypertension. Women would be expected to realize the greatest population improvements with increase in FV consumption. Conclusion: Increasing fruit and vegetable consumption among US adults could yield considerable population health benefits in prevention of cardiovascular disease and death, particularly for those with existing hypertension.

From Spreadsheets to Script: Experiences From Converting a Scottish Cardiovascular Disease Policy Model into R.

Given the advantages in transparency, reproducibility, adaptability and computational efficiency in R, there is a growing interest in converting existing spreadsheet-based models into an R script for model re-use and upskilling training among health economic modellers. The objective of this exercise was to convert the Scottish Cardiovascular Disease (CVD) Policy Model from Excel to R and discuss the lessons learnt throughout this process. The CVD model is a competing risk state transition cohort model. Four health economists, with varied experience of R, attempted to replicate an identical model structure in R based on the model in Excel and reproduce the intermediate and final results. Replications varied in their use of specialist health economics packages in addition to standard data management packages. Two versions of the CVD model were created in R along with a Shiny app. Version 1 was developed without health economics specialist packages and produced identical results to the Excel version. Version 2 used the heemod package and did not achieve the same results, possibly due to the non-standard elements of the model and limited time to adapt the functions. The R model requires less than half the computational time than the Excel model. Conversion of the spreadsheet models to script models is feasible for health economists. A step-by-step guide for the conversion process is provided and modellers' experience is discussed. Coding without specialist packages allows full flexibility, while specialist packages may add convenience if the model structure is suitable. Whichever approach is taken, transparency and replicability remain the key criteria in model programming. Model conversions must maintain standards in these areas regardless of the choice of software.

Use of simulation models in health economic evaluation studies of dietary salt-reduction policies for cardiovascular disease prevention

Objectives Social security costs related to the healthcare and long-term care of patients with cardiovascular diseases is a national burden that is expected to grow as Japan's population ages. Nutritional policies for improving the nation's diet could prevent cardiovascular diseases, but scientific evidence on their costs and outcomes is limited. This study gives an overview of health economic evaluation studies on population-wide dietary salt-reduction policies that have been instituted for the purposes of cardiovascular disease prevention. Thus, this study provides background information for the development of evaluation methods that can be utilized in Japan for analyzing the effects of nutritional policies on public health and social security cost containment.Methods We extracted representative health economic simulation models that are used for predicting the effects of cardiovascular disease-related interventions: Cardiovascular Disease Policy Model, IMPACT Coronary Heart Disease Policy and Prevention Model, US IMPACT Food Policy Model, Assessing Cost-Effectiveness (ACE) approach to priority-setting, and Prevention Impacts Simulation Model (PRISM). Next, we collected original articles on studies that used these models for assessing the costs and effects of national population-wide dietary salt-reduction policies. We then outlined the background, structure, and applied studies associated with each model.Results The five models utilized Markov cohort simulation, microsimulation, proportional multistate life tables, and system dynamics to predict the effect of dietary salt-reduction policies on blood pressure reduction and cardiovascular disease prevention. The models were applied to countries such as Australia, England, and the United States to simulate long-term (10 years to lifetime) costs and effects. These applied studies examined policies that included health promotion campaigns, sodium labels on the front of food packages, and mandatory or voluntary reformulation by the food industry to reduce the salt content of processed foods.Conclusion Health economic simulation modeling is actively being used to evaluate scientific evidence on the costs and outcomes of national dietary salt-reduction policies. Similarly, leveraging simulation modeling techniques could facilitate the evaluation and planning of dietary salt-reduction policies and other nutritional policies in Japan.

Health Impact and Cost-Effectiveness of Achieving the National Salt and Sugar Reduction Initiative Voluntary Sugar Reduction Targets in the United States: A Microsimulation Study.

High intake of added sugar is linked to weight gain and cardiometabolic risk. In 2018, the US National Salt and Sugar Reduction Initiative proposed government-supported voluntary national sugar reduction targets. This intervention's potential effects and cost-effectiveness are unclear. A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), coded in C++, was used to estimate incremental changes in type 2 diabetes, cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the US National Salt and Sugar Reduction Initiative policy. The model was run at the individual level, incorporating the annual probability of each person's transition between health statuses on the basis of risk factors. The model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across 3 cycles (2011 through 2016), added sugar-related diseases from meta-analyses, and policy costs and health-related costs from established sources. A simulated nationally representative US population was created and followed until age 100 years or death, with 2019 as the year of intervention start. Findings were evaluated over 10 years and a lifetime from health care and societal perspectives. Uncertainty was evaluated in a 1-way analysis by assuming 50% industry compliance and probabilistic sensitivity analyses through a second-order Monte Carlo approach. Model outputs included averted diabetes cases, CVD events and CVD deaths, QALYs gained, and formal health care cost savings, stratified by age, race, income, and education. Achieving the US National Salt and Sugar Reduction Initiative sugar reduction targets could prevent 2.48 million CVD events, 0.49 million CVD deaths, and 0.75 million diabetes cases; gain 6.67 million QALYs; and save $160.88 billion net costs from a societal perspective over a lifetime. The policy became cost-effective (<150 000/QALYs) at 6 years, highly cost-effective (<50 000/QALYs) at 7 years, and cost-saving at 9 years. Results were robust from a health care perspective, with lower (50%) industry compliance, and in probabilistic sensitivity analyses. The policy could also reduce disparities, with greatest estimated health gains per million adults among Black or Hispanic individuals, lower income, and less educated Americans. Implementing and achieving the US National Salt and Sugar Reduction Initiative sugar reformation targets could generate substantial health gains, equity gains, and cost savings.

PCV15 Cost-Effectiveness of Screening for and Treating Masked Hypertension with out-of-Office Blood Pressure Monitoring

Masked hypertension (office blood pressure [BP] <130/80 mmHg, out-of-office BP ≥130/80 mmHg) increases cardiovascular disease (CVD) event risk nearly two-fold compared to sustained normotension (office BP <130/80 mmHg, out-of-office BP <130/80 mmHg) . We compared the lifetime health and economic outcomes of screening for and treating masked hypertension by adding ambulatory or home BP monitoring (i.e., ABPM or HBPM) to standard care (no screening) from a US healthcare sector perspective. The CVD Policy Model, a microsimulation health state transition model, simulates the annual risk of fatal and non-fatal CVD events, treatment-related adverse events, and non-CVD deaths. We simulated screening of 500,000 US adults aged ≥20 years at risk for masked hypertension (office BP 120-129/<80 mmHg, on no antihypertensive medications, without CVD history). Based on published literature, we assumed ABPM had 100% sensitivity and 100% specificity (gold standard), and HBPM had 91.8% sensitivity and 41.4% specificity. We projected total direct health care costs (2020 USD), quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs). Future costs and QALYs were discounted 3% annually. A threshold of <$150,000/QALY gained defined intermediate cost-effectiveness. Primary analyses were performed using 100 probabilistic simulations. Parameter uncertainty was assessed using one-way sensitivity analyses. Relative to standard care, mean (95%CI) time to first CVD event increased with ABPM 0.232 (0.152-0.326) years and 0.233 (0.149-0.328) years with HBPM masked hypertension screening, but the percent experiencing treatment-related serious adverse events increased 10.9% (9.8%-11.7%) with ABPM and 11.4% (11.1%-11.7%) with HBPM. Compared to standard care, lifetime QALYs increased 0.018 (0.005-0.034) with ABPM and 0.017 (0.003-0.032) with HBPM screening, but neither strategy was cost-effective (ICER: ABPM $433,000/QALY gained, HBPM $428,000/QALY gained). No sensitivity analyses resulted in either ABPM or HBPM becoming cost-effective. Screening for masked hypertension with ABPM or HBPM leads to modest health gains but is not cost-effective compared to standard care.

Risk of fatal and nonfatal coronary heart disease and stroke events among adult patients with hypertension: basic Markov model inputs for evaluating cost-effectiveness of hypertension treatment: systematic review of cohort studies

Abstract Objectives Hypertension is a risk factor for a number of vascular and cardiac complications. A Markov like simulation based on cardiovascular disease (CVD) policy model is being used for evaluating cost-effectiveness of hypertension treatment. Stroke, angina, myocardial infarction (MI), cardiac arrest and all-cause mortality were only included CVD outcome variables in the model. Therefore this systematic review was conducted to evaluate completeness of CVD policy model for evaluation of cost-effectiveness across different regions. Key findings Fourteen cohort studies involving a total of 1 674 773 hypertensive adult population and 499 226 adults with treatment resistant hypertension were included in this systematic review. Hypertension is clearly associated with coronary heart disease (CHD) and stroke mortality, unstable angina, stable angina, MI, heart failure (HF), sudden cardiac death, transient ischemic attack, ischemic stroke, sub-arachnoid hemorrhage, intracranial hemorrhage, peripheral arterial disease (PAD), and abdominal aortic aneurism (AAA). Lifetime risk of developing HF is higher among hypertensives across all ages, with slight variation among regions. Treatment resistant hypertension is associated with higher relative risk of developing major CVD events and mortality when compared with the non-resistant hypertension. Summary The CVD policy model can be used in most of the regions for evaluation of cost-effectiveness of hypertension treatment. However, hypertension is highly associated with HF in Latin America, Eastern Europe, and Sub-Saharan Africa. Therefore, it is important to consider HF in CVD policy model for evaluating cost-effectiveness of hypertension treatment in these regions. We do not suggest the inclusion of PAD and AAA in CVD policy model for evaluating cost-effectiveness of hypertension treatment due to lack of sufficient evidence. Researchers should consider the effect of treatment resistant hypertension either through including in the basic model or during setting the model assumptions.

Long-term health outcomes of people with reduced kidney function in the UK: A modelling study using population health data.

People with reduced kidney function have increased cardiovascular disease (CVD) risk. We present a policy model that simulates individuals' long-term health outcomes and costs to inform strategies to reduce risks of kidney and CVDs in this population. We used a United Kingdom primary healthcare database, the Clinical Practice Research Datalink (CPRD), linked with secondary healthcare and mortality data, to derive an open 2005-2013 cohort of adults (≥18 years of age) with reduced kidney function (≥2 measures of estimated glomerular filtration rate [eGFR] <90 mL/min/1.73 m2 ≥90 days apart). Data on individuals' sociodemographic and clinical characteristics at entry and outcomes (first occurrences of stroke, myocardial infarction (MI), and hospitalisation for heart failure; annual kidney disease stages; and cardiovascular and nonvascular deaths) during follow-up were extracted. The cohort was used to estimate risk equations for outcomes and develop a chronic kidney disease-cardiovascular disease (CKD-CVD) health outcomes model, a Markov state transition model simulating individuals' long-term outcomes, healthcare costs, and quality of life based on their characteristics at entry. Model-simulated cumulative risks of outcomes were compared with respective observed risks using a split-sample approach. To illustrate model value, we assess the benefits of partial (i.e., at 2013 levels) and optimal (i.e., fully compliant with clinical guidelines in 2019) use of cardioprotective medications. The cohort included 1.1 million individuals with reduced kidney function (median follow-up 4.9 years, 45% men, 19% with CVD, and 74% with only mildly decreased eGFR of 60-89 mL/min/1.73 m2 at entry). Age, kidney function status, and CVD events were the key determinants of subsequent morbidity and mortality. The model-simulated cumulative disease risks corresponded well to observed risks in participant categories by eGFR level. Without the use of cardioprotective medications, for 60- to 69-year-old individuals with mildly decreased eGFR (60-89 mL/min/1.73 m2), the model projected a further 22.1 (95% confidence interval [CI] 21.8-22.3) years of life if without previous CVD and 18.6 (18.2-18.9) years if with CVD. Cardioprotective medication use at 2013 levels (29%-44% of indicated individuals without CVD; 64%-76% of those with CVD) was projected to increase their life expectancy by 0.19 (0.14-0.23) and 0.90 (0.50-1.21) years, respectively. At optimal cardioprotective medication use, the projected health gains in these individuals increased by further 0.33 (0.25-0.40) and 0.37 (0.20-0.50) years, respectively. Limitations include risk factor measurements from the UK routine primary care database and limited albuminuria measurements. The CKD-CVD policy model is a novel resource for projecting long-term health outcomes and assessing treatment strategies in people with reduced kidney function. The model indicates clear survival benefits with cardioprotective treatments in this population and scope for further benefits if use of these treatments is optimised.

Health Impact and Cost-Effectiveness of Volume, Tiered, and Absolute Sugar Content Sugar-Sweetened Beverage Tax Policies in the United States: A Microsimulation Study.

Sugar-sweetened beverage taxes are a rapidly growing policy tool and can be based on absolute volume, sugar content tiers, or absolute sugar content. Yet, their comparative health and economic impacts have not been quantified, in particular, tiered or sugar content taxes that provide industry incentives for sugar reduction. We estimated incremental changes in diabetes mellitus and cardiovascular disease, quality-adjusted life-years, costs, and cost-effectiveness of 3 sugar-sweetened beverage tax designs in the United States, on the basis of (1) volume ($0.01/oz), (2) tiers (<5 g of added sugar/8 oz: no tax; 5-20 g/8 oz: $0.01/oz; and >20 g/8 oz: $0.02/oz), and (3) absolute sugar content ($0.01 per teaspoon added sugar), each compared with a base case of modest ongoing voluntary industry reformulation. A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey, policy effects and sugar-sweetened beverage-related diseases from meta-analyses, and industry reformulation and health-related costs from established sources. Over a lifetime, the volume, tiered, and absolute sugar content taxes would generate $80.4 billion, $142 billion, and $41.7 billion in tax revenue, respectively. From a healthcare perspective, the volume tax would prevent 850 000 cardiovascular disease (95% CI, 836 000-864 000) and 269 000 diabetes mellitus (265 000-274 000) cases, gain 2.44 million quality-adjusted life-years (2.40-2.48), and save $53.2 billion net costs (52.3-54.1). Health gains and savings were approximately doubled for the tiered and absolute sugar content taxes. Results were robust for societal and government perspectives, at 10 years follow-up, and with lower (50%) tax pass-through. Health gains were largest in young adults, blacks and Hispanics, and lower-income Americans. All sugar-sweetened beverage tax designs would generate substantial health gains and savings. Tiered and absolute sugar content taxes should be considered and evaluated for maximal potential gains.