TABLE 7.5aSummary of Economic Analyses for Population-Based and Other Lifestyle CVD Intervention Approaches for Low and Middle Income Countries

Intervention TypeReferenceCountry/SettingInterventionComparatorMethodaOutcome or Assumed OutcomeaEconomic Analysis ResultaCost Effective?
Tobacco Controlb
Lai et al., 2007EstoniaIncrease taxes from 49% to 60%Current situationWHO CHOICE ModelingAssumed 3.4% decline in tobacco consumptionICER: 218 EEK/DALY avertedY <per capita GDP (90454 EEK)
EstoniaTaxes and advertising bans on smokingTaxes onlyWHO CHOICE ModelingAssumed 3.4% decline in tobacco consumption PLUS 5% decline in new smokersICER: 304 EEK/DALYY
EstoniaTaxes, ad ban, and clean indoor airTaxes and ad banWHO CHOICE ModelingAssumed 3.4% decline in tobacco consumption PLUS 5% decline in new smokers PLUS
5% decline in the incidence of smoking among male smokers, and 2.4% decline among female smokers
ICER: 453 EEK/DALYY
Gaziano, 2008Sub-Saharan AfricaTobacco taxation— price increase 33%NullModelingAssumed a reduction in future tobacco deaths of 5.4%–15.9%ICER: US$2–26/DALYNot reported
Sub-Saharan AfricaTobacco regulation (non-price intervention such as labeling, advertising bans)NullModelingAssumed a reduction in future tobacco deaths of 1.6%–7.9%ICER: US$33–417/DALYNot reported
Thavorn and Chaiyakunapruk, 2008ThailandIndividual health education for tobacco cessationUsual care: screening and brief advice and supportModelingAssumed a 14.3% smoking cessation rate (with no relapse) with a corresponding assumed reduction in events and mortality due to COPD, AMI, CHF, angina, and strokeCost savings of 17503 baht (£250; €325; US$500) to the health system and life year gains of 0.18 years for men

Cost savings of 21 499.75 baht (£307; €399; $614) and life year gains of 0.24 years for women
Y
Food Regulation
Rubinstein et al., 2009Argentina (Buenos Aires)Regulation of salt content of breadNullModeling Popmod (WHO)Assumed that a 1g of salt reduction per 100g of bread led to a reduction of 1.33mmHg in systolic blood pressure per person and 1% of the population-attributable risk of CHD and strokeICER: 151 ARG$/DALYY
Based on <3× per capita GNI
Murray et al., 2003Latin AmericaSalt reduction— industry agreementsNullPopmod multi- state modelingAssumed blood pressure changes specific for region, age, and sex associated with a 15% reduction in total dietary salt intakeAverage CER: US$24/DALYY based on < per capita GDP
Latin AmericaSalt reduction— legislationNullPopmod multi- state modelingAssumed blood pressure changes specific for region, age, and sex associated with a 30% reduction in total dietary salt intakeAverage CER: US$13/DALYY
South-East AsiaSalt reduction— industry agreementsNullPopmod multi- state modelingAssumed blood pressure changes specific for region, age, and sex associated with a 15% reduction in total dietary salt intakeAverage CER: US$37/DALYY
South-East AsiaSalt reduction— legislationNullPopmod multi- state modelingAssumed blood pressure changes specific for region, age, and sex associated with a 30% reduction in total dietary salt intakeAverage CER: US$19/DALYY
Gaziano, 2008Sub-Saharan AfricaSubstitution of polyunsaturated fats for 2% of dietary transfatsNullPopmod multi-state modelingAssumed reduction in CAD of 7% to 40%ICER: US$53–1344/DALY at 7%
Cost saving US$ −184 at 40%
Y
Physical Activity
Matsudo et al., 2006BrazilPopulation-based physical activity promotionModelingAssumptions for model unknownCost Utility Analysis: Cost savingY
Salvetti et al., 2008BrazilHome-based training for physical post-MIStandard careRCTOverall biomedical measures of cardiovascular function and self-reported measures of quality of life improved in the intervention group and remained constant or worsened in the control groupProtocol cost $502.71 (BHCMP) per patient for 3 monthsNot reported
Health Education
Murray et al., 2003South-East AsiaHealth education focusing on lowering BMI and cholesterolNullPopmod multi- state modelingAssumed a 2% reduction in total blood cholesterol concentrationsAverage CER: US$14/DALYY based on < per capita GDP
Latin AmericaHealth education focusing on lowering BMI and cholesterolNullPopmod multi- state modelingAssumed a 2% reduction in total blood cholesterol concentrationsAverage CER: US$14/DALYY
Getpreechaswas et al., 2007ThailandSocial marketing through trained health personnel, village health volunteers, and family health leadersInterview onlyObservational trialThe intervention group showed a significant improvement in dietary patters, physical activity, and stress reduction and a significant decrease in tobacco and alcohol use compared to the control groupCosts: 74.89 baht per head of populationNot reported
García-Peña et al., 2002MexicoHealth education in home visits by nurse to elderly people with hypertensionNo interventionRCTA reduction of 3.31 mm Hg in SBP and 3.67 mm Hg in DBP in the intervention group compared to the control group. In the intervention group, 12.9% of participants reported an increase in brisk walking, compared with 5.2% in the control group. The proportion of people on anti-hypertensive medication decreased from 28.4% to 15.9%, compared to a decrease from 32.2% to 26.9% in the control groupCER: 10.46 pesos (US$1.14) per mmHg reduced for SBP
9.43 (US$1.03) per mmHg reduced for DBP
Not possible to conclude
Huang et al., 2000, and Chen et al., 2008Beijing ChinaCommunity-based CVD program including education and risk-targeted high blood pressure medication (Beijing Fangshan CVD Prevention Program)NullObservational cohortObserved a net reduction in SBP/DBP in the intervention group compared to the control group of −1.4/.05 mmHg in men and −3.4/−1.0 in women. Observed a reduction in morbidity and mortality of stroke of 18.7% in the intervention group compared to 17.7% in the control group. Observed a reduction in morbidity and mortality of CHD of 4.9% in the intervention group compared to 4.3% in the control group.ICER: 1992 1586 yuan/DALY
1993 1380 yuan/DALY
ICER: Cost saving from 1994–1997
Cost saving
Rubinstein et al., 2009Argentina (Buenos Aires)Health education through mass mediaNullModelling Popmod (WHO)Assume a reduction of 1.83mmHg in systolic blood pressure and 0.02mm/l in cholesterol (t), leading to a reduction of 2% of the population attributable risk of CHD and strokeICER: 547 ARG$/DALYY
Based on <3× per capita GNI
Rossouw et al., 1993South AfricaSocial Marketing (CORIS)No interventionObservational trialFor men there was a reduction in risk score of 1.3% in the control group, 3.7% in the low-intensity intervention group, and 3.7% in the high- intensity intervention group

For women there was a reduction in risk score of 1.6% in the control group, 4.7% in the low-intensity intervention group, and 4.4% in the high- intensity intervention group
$5 per capita cost for low intensity; $22 per capita cost for high intensityNot reported
Multiple StrategiesAsaria et al., 2007Multi- nationalPopulation-based strategies to reduce salt consumption by 15% and a 43.2% increase in the price of tobacco combined with non-price interventionsNo treatmentModelingSalt Reduction
Assumed the reduction in salt intake lead to an age-stratified decrease in mmHg of SPB of 1.24 (30–44), 1.7 (45–59), 2.34 (60–69), 2.83 (70–79), 3.46 (80–100)

Tobacco prices Assumed the non-price interventions lead to a 12% decrease in smoking prevalence Assumed the increase in price of tobacco lead to a 20.8% decrease in smoking prevalence
Costs range from US$0.14–1.04 per person per year to avert approximately 13.8 million deaths from CVD, respiratory disease, and cancer over 10 yearsNot reported
a

Sources of data on intervention effectiveness and costs for modeling assumptions vary widely across studies and in some cases are drawn from high income country information.

b

For tobacco control, see also reviews by Chisholm et al., 2006; Jha et al., 2006; and Shibuya et al., 2003.

NOTE: AMI = Acute Myocardial Infarction; CAD = Coronary Artery Disease; CER = Cost-Effectiveness Ratio; CHD = Coronary Heart Disease; CHF = Congestive Heart Failure; COPD = Chronic Obstructive Pulmonary Disease; CVD = Cardiovascular Disease; DALY = Disability-Adjusted Life Year; GDP = Gross Domestic Product; GNI = Gross National Income; ICER = Incremental Cost-Effectiveness Ratio; RCT = Randomized Controlled Trial; WHO = World Health Organization.

From: 7, Making Choices to Reduce the Burden of Cardiovascular Disease

Cover of Promoting Cardiovascular Health in the Developing World
Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health.
Institute of Medicine (US) Committee on Preventing the Global Epidemic of Cardiovascular Disease: Meeting the Challenges in Developing Countries; Fuster V, Kelly BB, editors.
Washington (DC): National Academies Press (US); 2010.
Copyright © 2010, National Academy of Sciences.

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