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Oude Wolcherink MJ, Behr CM, Pouwels XGLV, Doggen CJM, Koffijberg H. Health Economic Research Assessing the Value of Early Detection of Cardiovascular Disease: A Systematic Review. PHARMACOECONOMICS 2023; 41:1183-1203. [PMID: 37328633 PMCID: PMC10492754 DOI: 10.1007/s40273-023-01287-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/22/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Cardiovascular disease (CVD) is the most prominent cause of death worldwide and has a major impact on healthcare budgets. While early detection strategies may reduce the overall CVD burden through earlier treatment, it is unclear which strategies are (most) efficient. AIM This systematic review reports on the cost effectiveness of recent early detection strategies for CVD in adult populations at risk. METHODS PubMed and Scopus were searched to identify scientific articles published between January 2016 and May 2022. The first reviewer screened all articles, a second reviewer independently assessed a random 10% sample of the articles for validation. Discrepancies were solved through discussion, involving a third reviewer if necessary. All costs were converted to 2021 euros. Reporting quality of all studies was assessed using the CHEERS 2022 checklist. RESULTS In total, 49 out of 5552 articles were included for data extraction and assessment of reporting quality, reporting on 48 unique early detection strategies. Early detection of atrial fibrillation in asymptomatic patients was most frequently studied (n = 15) followed by abdominal aortic aneurysm (n = 8), hypertension (n = 7) and predicted 10-year CVD risk (n = 5). Overall, 43 strategies (87.8%) were reported as cost effective and 11 (22.5%) CVD-related strategies reported cost reductions. Reporting quality ranged between 25 and 86%. CONCLUSIONS Current evidence suggests that early CVD detection strategies are predominantly cost effective and may reduce CVD-related costs compared with no early detection. However, the lack of standardisation complicates the comparison of cost-effectiveness outcomes between studies. Real-world cost effectiveness of early CVD detection strategies will depend on the target country and local context. REGISTRATION OF SYSTEMATIC REVIEW CRD42022321585 in International Prospective Registry of Ongoing Systematic Reviews (PROSPERO) submitted at 10 May 2022.
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Affiliation(s)
- Martijn J Oude Wolcherink
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Carina M Behr
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Xavier G L V Pouwels
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Carine J M Doggen
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands
| | - Hendrik Koffijberg
- Health Technology and Services Research, Techmed Centre, University of Twente, Enschede, The Netherlands.
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Wijemunige N, Rannan-Eliya RP, van Baal P, O'Donnell O. Optimizing cardiovascular disease risk screening in a low-resource setting: cost-effectiveness of program modifications in Sri Lanka modelled with nationally representative survey data. BMC Public Health 2023; 23:1792. [PMID: 37715157 PMCID: PMC10503056 DOI: 10.1186/s12889-023-16640-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 08/29/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND While screening for cardiovascular disease (CVD) risk can help low-resource health systems deliver low-cost, effective prevention, evidence is needed to adapt international screening guidelines for maximal impact in local settings. We aimed to establish how the cost-effectiveness of CVD risk screening in Sri Lanka varies with who is screened, how risk is assessed, and what thresholds are used for prescription of medicines. METHODS We used data for people aged 35 years and over from a 2018/19 nationally representative survey in Sri Lanka. We modelled the costs and quality adjusted life years (QALYs) for 128 screening program scenarios distinguished by a) age group screened, b) risk tool used, c) definition of high CVD risk, d) blood pressure threshold for treatment of high-risks, and e) prescription of statins to all diabetics. We used the current program as the base case. We used a Markov model of a one-year screening program with a lifetime horizon and a public health system perspective. RESULTS Scenarios that included the WHO-2019 office-based risk tool dominated most others. Switching to this tool and raising the age threshold for screening from 35 to 40 years gave an incremental cost-effectiveness ratio (ICER) of $113/QALY. Lowering the CVD high-risk threshold from 20 to 10% and prescribing antihypertensives at a lower threshold to diabetics and people at high risk of CVD gave an ICER of $1,159/QALY. The findings were sensitive to allowing for disutility of daily medication. CONCLUSIONS In Sri Lanka, CVD risk screening scenarios that used the WHO-2019 office-based risk tool, screened people above the age of 40, and lowered risk and blood pressure thresholds would likely be cost-effective, generating an additional QALY at less than half a GDP per capita.
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Affiliation(s)
- Nilmini Wijemunige
- Institute for Health Policy, 72 Park Street, Colombo 2, Colombo, Western Province, Sri Lanka.
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Ravindra P Rannan-Eliya
- Institute for Health Policy, 72 Park Street, Colombo 2, Colombo, Western Province, Sri Lanka
| | - Pieter van Baal
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Owen O'Donnell
- Erasmus School of Economics and Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Stol DM, Over EAB, Badenbroek IF, Hollander M, Nielen MMJ, Kraaijenhagen RA, Schellevis FG, de Wit NJ, de Wit GA. Cost-effectiveness of a stepwise cardiometabolic disease prevention program: results of a randomized controlled trial in primary care. BMC Med 2021; 19:57. [PMID: 33691699 PMCID: PMC7948329 DOI: 10.1186/s12916-021-01933-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cardiometabolic diseases (CMD) are the major cause of death worldwide and are associated with a lower quality of life and high healthcare costs. To prevent a further rise in CMD and related healthcare costs, early detection and adequate management of individuals at risk could be an effective preventive strategy. The objective of this study was to determine long-term cost-effectiveness of stepwise CMD risk assessment followed by individualized treatment if indicated compared to care as usual. A computer-based simulation model was used to project long-term health benefits and cost-effectiveness, assuming the prevention program was implemented in Dutch primary care. METHODS A randomized controlled trial in a primary care setting in which 1934 participants aged 45-70 years without recorded CMD or CMD risk factors participated. The intervention group was invited for stepwise CMD risk assessment through a risk score (step 1), additional risk assessment at the practice in case of increased risk (step 2) and individualized follow-up treatment if indicated (step 3). The control group was not invited for risk assessment, but completed a health questionnaire. Results of the effectiveness analysis on systolic blood pressure (- 2.26 mmHg; 95% CI - 4.01: - 0.51) and total cholesterol (- 0.15 mmol/l; 95% CI - 0.23: - 0.07) were used in this analysis. Outcome measures were the costs and benefits after 1-year follow-up and long-term (60 years) cost-effectiveness of stepwise CMD risk assessment compared to no assessment. A computer-based simulation model was used that included data on disability weights associated with age and disease outcomes related to CMD. Analyses were performed taking a healthcare perspective. RESULTS After 1 year, the average costs in the intervention group were 260 Euro higher than in the control group and differences were mainly driven by healthcare costs. No meaningful change was found in EQ 5D-based quality of life between the intervention and control groups after 1-year follow-up (- 0.0154; 95% CI - 0.029: 0.004). After 60 years, cumulative costs of the intervention were 41.4 million Euro and 135 quality-adjusted life years (QALY) were gained. Despite improvements in blood pressure and cholesterol, the intervention was not cost-effective (ICER of 306,000 Euro/QALY after 60 years). Scenario analyses did not allow for a change in conclusions with regard to cost-effectiveness of the intervention. CONCLUSIONS Implementation of this primary care-based CMD prevention program is not cost-effective in the long term. Implementation of this program in primary care cannot be recommended. TRIAL REGISTRATION Dutch Trial Register NTR4277 , registered on 26 November 2013.
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Affiliation(s)
- Daphne M. Stol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Eelco A. B. Over
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Ilse F. Badenbroek
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Monika Hollander
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark M. J. Nielen
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Roderik A. Kraaijenhagen
- Netherlands Institute for Prevention and E-health Development (NIPED), Amsterdam, The Netherlands
| | - François G. Schellevis
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers (location VUmc), Amsterdam, The Netherlands
| | - Niek J. de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - G. Ardine de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
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Stol DM, Hollander M, Badenbroek IF, Nielen MMJ, Schellevis FG, de Wit NJ. Uptake and detection rate of a stepwise cardiometabolic disease detection program in primary care-a cohort study. Eur J Public Health 2020; 30:479-484. [PMID: 31722402 PMCID: PMC7292350 DOI: 10.1093/eurpub/ckz201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Early detection and treatment of cardiometabolic diseases (CMD) in high-risk patients is a promising preventive strategy to anticipate the increasing burden of CMD. The Dutch guideline ‘the prevention consultation’ provides a framework for stepwise CMD risk assessment and detection in primary care. The aim of this study was to assess the outcome of this program in terms of newly diagnosed CMD. Methods A cohort study among 30 934 patients, aged 45–70 years without known CMD or CMD risk factors, who were invited for the CMD detection program within 37 general practices. Patients filled out a CMD risk score (step 1), were referred for additional risk profiling in case of high risk (step 2) and received lifestyle advice and (pharmacological) treatment if indicated (step 3). During 1-year follow-up newly diagnosed CMD, prescriptions and abnormal diagnostic tests were assessed. Results Twelve thousand seven hundred and thirty-eight patients filled out the risk score of which 865, 6665 and 5208 had a low, intermediate and high CMD risk, respectively. One thousand seven hundred and fifty-five high-risk patients consulted the general practitioner, in 346 of whom a new CMD was diagnosed. In an additional 422 patients a new prescription and/or abnormal diagnostic test were found. Conclusions Implementation of the CMD detection program resulted in a new CMD diagnosis in one-fifth of high-risk patients who attended the practice for completion of their risk profile. However, the potential yield of the program could be higher given the considerable number of additional risk factors—such as elevated glucose, blood pressure and cholesterol levels—found, requiring active follow-up and presumably treatment in the future.
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Affiliation(s)
- Daphne M Stol
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Correspondence: Daphne M. Stol, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands, Tel: +31 887568181, e-mail:
| | - Monika Hollander
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ilse F Badenbroek
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Mark M J Nielen
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - François G Schellevis
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers (Location VUmc), Amsterdam, The Netherlands
| | - Niek J de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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de Waard AKM, Hollander M, Korevaar JC, Nielen MMJ, Carlsson AC, Lionis C, Seifert B, Thilsing T, de Wit NJ, Schellevis FG. Selective prevention of cardiometabolic diseases: activities and attitudes of general practitioners across Europe. Eur J Public Health 2019; 29:88-93. [PMID: 30016426 PMCID: PMC6345147 DOI: 10.1093/eurpub/cky112] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Cardiometabolic diseases (CMDs) are the number one cause of death. Selective prevention of CMDs by general practitioners (GPs) could help reduce the burden of CMDs. This measure would entail the identification of individuals at high risk of CMDs—but currently asymptomatic—followed by interventions to reduce their risk. No data were available on the attitude and the extent to which European GPs have incorporated selective CMD prevention into daily practice. Methods A survey among 575 GPs from the Czech Republic, Denmark, Greece, the Netherlands and Sweden was conducted between September 2016 and January 2017, within the framework of the SPIMEU-project. Results On average, 71% of GPs invited their patients to attend for CMD risk assessment. Some used an active approach (47%) while others used an opportunistic approach (53%), but these values differed between countries. Most GPs considered selective CMD prevention as useful (82%) and saw it as part of their normal duties (84%). GPs who did find selective prevention useful were more likely to actively invite individuals compared with their counterparts who did not find prevention useful. Most GPs had a disease management programme for individuals with risk factor(s) for cardiovascular disease (71%) or diabetes (86%). Conclusions Although most GPs considered selective CMD prevention as useful, it was not universally implemented. The biggest challenge was the process of inviting individuals for risk assessment. It is important to tailor the implementation of selective CMD prevention in primary care to the national context, involving stakeholders at different levels.
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Affiliation(s)
- Anne-Karien M de Waard
- Department of General Practice, Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Monika Hollander
- Department of General Practice, Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Joke C Korevaar
- Nivel (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
| | - Mark M J Nielen
- Nivel (Netherlands Institute for Health Services Research), Utrecht, The Netherlands
| | - Axel C Carlsson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden.,Department of Medical Sciences, Cardiovascular Epidemiology, Uppsala University, Uppsala, Sweden
| | - Christos Lionis
- Clinic of Social and Family Medicine, School of Medicine, University of Crete, Greece
| | - Bohumil Seifert
- Institute of General Practice, First Faculty of Medicine, Charles University, Prague, The Czech Republic
| | - Trine Thilsing
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Niek J de Wit
- Department of General Practice, Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - François G Schellevis
- Nivel (Netherlands Institute for Health Services Research), Utrecht, The Netherlands.,Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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