Cost-effectiveness of medical interventions to prevent cardiovascular disease in a sub-Saharan African country – the case of Tanzania

Robberstad Bjarne, Hemed Yusuf, Norheim

Description

There is a high and rising prevalence of cardiovascular risk in sub-Saharan Africa, a development typical for countries in epidemiological transition. Contrary to recommendations in treatment guidelines, medical interventions to prevent cardiovascular disease are implemented only on a limited scale in these settings. There is a widespread concern that such treatment is not cost-effective compared to alternative health interventions. The main objectives of this article are therefore to calculate costs-, effects and cost-effectiveness of fourteen medical interventions of primary prevention of cardiovascular disease in Tanzania, including Acetylsalicylic acid, a diuretic drug (Hydrochlorothiazide), a β-blocker (Atenolol), a calcium channel blocker (Nifedepine), a statin (Lovastatin) and various combinations of these. Methods Effect sizes were derived from systematic reviews or meta-analyses, and calculated as Disability Adjusted Life Years (DALYs). Data on drug costs were calibrated to a Tanzanian setting. Other recurrent and capital costs were derived from previous studies and reviewed by local experts. Expected lifetime costs and health outcomes were calculated using a life-cycle model. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability curves and frontiers. The potential impacts of uncertainty in value laden single parameters were explored in one-way sensitivity analyses. Results The incremental cost-effectiveness ratios for the fourteen interventions and four different levels of risk (totally 56 alternative interventions) ranged from about USD 85 per DALY to about USD 4589 per DALY saved. Hydrochlorothiazide as monotherapy is the drug yielding the most favorable cost-effectiveness ratio, although not significantly lower than when it is combined in duo-therapy with Aspirin or a β-blocker, in triple-therapy with Aspirin and a β-blocker, or than Aspirin given as mono-therapy. Conclusion Preventive cardiology is not cost-effective for any patient group in this setting until willingness to pay exceeds USD 85 per DALY. At this level of willingness to pay, the optimal intervention is Hydrochlorothiazide to patients with very high cardiovascular risk. As willingness to pay for health increase further, it becomes optimal to provide this treatment also to patients with lower cardiovascular risk, and to substitute to more sophisticated interventions.

Informations

• Publié par: biomed
• Publié le: 01 janvier 2007
• Nombre de lectures: 4
• Langue: English

Extrait

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Published: 22 February 2007 Received: 19 June 2006 Cost Effectiveness and Resource Allocation 2007, 5 :3 doi:10.1186/1478-7547-5-3  Accepted: 22 February 2007 This article is available from: http:/ /www.resource-allocation.com/content/5/1/3 © 2007 Robberstad et al; lic ensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the orig inal work is properly cited.

Address: 1 Department of Public Health and Primary Care, University of Bergen , P.o.Box 7804, 5020 Bergen, Norway and 2 MEASURE Evaluation, P.O Box 65243, Dar es Salaam, Tanzania Email: Bjarne Robberstad* - bjarne.robberstad@ cih.uib.no; Yusuf Hemed - [e-mail]; Ole F Norheim - [e-mail] * Corresponding author

Abstract Background: There is a high and rising prevalence of ca rdiovascular risk in sub-Saharan Africa, a development typical for countries in epidemiological transition. Contrary to recommendations in treatment guidelines, medical interv entions to prevent cardiovascular disease are implemented only on a limited scale in these setti ngs. There is a widespread concern that such treatment is not cost-effective compared to alternative health interv entions. The main objectives of this article are therefore to calculate costs-, effects and cost-effectiveness of fourteen medical in terventions of primary prevention of cardiovascular disease in Tanzania, including Acetylsali cylic acid, a diuretic drug (Hydrochlorothiazide), a β -blocker (Atenolol), a calcium channel blocker (N ifedepine), a statin (Lovastatin) and various combinations of these. Methods: Effect sizes were derived from sy stematic reviews or meta-analyse s, and calculated as Disability Adjusted Life Years (DALYs). Data on drug costs we re calibrated to a Tanzanian setting. Other recurrent and capital costs were derived from previous studies and reviewed by local experts. Expected lifetime costs and health outcomes were calculated using a life -cycle model. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and resu lts presented as cost-eff ectiveness acceptability curves and frontiers. The potential impacts of uncertainty in value lade n single parameters were explored in one-way sensitivity analyses. Results: The incremental cost-effectiveness ratios for the fourteen interv entions and four different levels of risk (totally 56 alternative interventions) rang ed from about USD 85 per DALY to about USD 4589 per DALY saved. Hydrochlorothiazide as monotherapy is the drug yiel ding the most favorable cost- effectiveness ratio, although not si gnificantly lower than when it is combined in duo-therapy with Aspirin or a β -blocker, in triple-therapy with Aspirin and a β -blocker, or than Aspirin given as mono-therapy. Conclusion: Preventive cardiology is no t cost-effective for any patien t group in this setting until willingness to pay exceeds USD 85 per DALY. At this level of willingness to pa y, the optimal intervention is Hydrochlorothiazide to patients with very high cardiovascular risk. As willingness to pay for health increase further, it becomes optima l to provide this treatment also to patients with lower cardiovascular risk, and to substitute to mo re sophisticated interventions.

Research Open Access Cost-effectiveness of medical interventions to prevent cardiovascular disease in a sub-Sa haran African country – the case of Tanzania Bjarne Robberstad* 1 , Yusuf Hemed 2 and Ole F Norheim 1