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      A Cost-Effectiveness Tool to Guide the Prioritization of Interventions for Rheumatic Fever and Rheumatic Heart Disease Control in African Nations

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          Abstract

          Background

          Rheumatic heart disease (RHD) prevalence and mortality rates remain especially high in many parts of Africa. While effective prevention and treatment exist, coverage rates of the various interventions are low. Little is known about the comparative cost-effectiveness of different RHD interventions in limited resource settings. We developed an economic evaluation tool to assist ministries of health in allocating resources and planning RHD control programs.

          Methodology/Principal Findings

          We constructed a Markov model of the natural history of acute rheumatic fever (ARF) and RHD, taking transition probabilities and intervention effectiveness data from previously published studies and expert opinion. Our model estimates the incremental cost-effectiveness of scaling up coverage of primary prevention (PP), secondary prevention (SP) and heart valve surgery (VS) interventions for RHD. We take a healthcare system perspective on costs and measure outcomes as disability-adjusted life-years (DALYs), discounting both at 3%. Univariate and probabilistic sensitivity analyses are also built into the modeling tool. We illustrate the use of this model in a hypothetical low-income African country, drawing on available disease burden and cost data. We found that, in our hypothetical country, PP would be cost saving and SP would be very cost-effective. International referral for VS (e.g., to a country like India that has existing surgical capacity) would be cost-effective, but building in-country VS services would not be cost-effective at typical low-income country thresholds.

          Conclusions/Significance

          Our cost-effectiveness analysis tool is designed to inform priorities for ARF/RHD control programs in Africa at the national or subnational level. In contrast to previous literature, our preliminary findings suggest PP could be the most efficient and cheapest approach in poor countries. We provide our model for public use in the form of a Supplementary File. Our research has immediate policy relevance and calls for renewed efforts to scale up RHD prevention.

          Author Summary

          Rheumatic heart disease is a major cause of cardiovascular morbidity and mortality in Africa. Although there are effective medications and surgical procedures for rheumatic heart disease, they are under-used. What is more, these interventions can be expensive—even if they are feasible and effective. Unfortunately, there are currently very few economic studies on rheumatic heart disease, leaving ministries of health with little guidance on how to choose among various interventions and allocate resources to control programs. Our study describes the methods and data we used to develop a cost-effectiveness analysis tool that was intended specifically for decision-making in African countries. In our study, we also illustrate, in a hypothetical low-income African country, how the tool could be used. In our illustrative example, a prevention-oriented approach would save money in the long term, although other interventions could be cost-effective and feasible if enough financial resources were present. These findings contrast with previous studies and make a strong case that rheumatic heart disease prevention could be a high-priority intervention in Africa. We are making our tool publicly available and anticipate that ministries of health will use it as they develop or expand their rheumatic heart disease control programs.

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          Most cited references21

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          Accelerating health equity: the key role of universal health coverage in the Sustainable Development Goals

          The Sustainable Development Goals (SDGs), to be committed to by Heads of State at the upcoming 2015 United Nations General Assembly, have set much higher and more ambitious health-related goals and targets than did the Millennium Development Goals (MDGs). The main challenge among MDG off-track countries is the failure to provide and sustain financial access to quality services by communities, especially the poor. Universal health coverage (UHC), one of the SDG health targets indispensable to achieving an improved level and distribution of health, requires a significant increase in government investment in strengthening primary healthcare - the close-to-client service which can result in equitable access. Given the trend of increased fiscal capacity in most developing countries, aiming at long-term progress toward UHC is feasible, if there is political commitment and if focused, effective policies are in place. Trends in high income countries, including an aging population which increases demand for health workers, continue to trigger international migration of health personnel from low and middle income countries. The inspirational SDGs must be matched with redoubled government efforts to strengthen health delivery systems, produce and retain more and relevant health workers, and progressively realize UHC.
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            Rheumatic heart disease

            Rheumatic heart disease, often neglected by media and policy makers, is a major burden in developing countries where it causes most of the cardiovascular morbidity and mortality in young people, leading to about 250,000 deaths per year worldwide. The disease results from an abnormal autoimmune response to a group A streptococcal infection in a genetically susceptible host. Acute rheumatic fever--the precursor to rheumatic heart disease--can affect different organs and lead to irreversible valve damage and heart failure. Although penicillin is effective in the prevention of the disease, treatment of advanced stages uses up a vast amount of resources, which makes disease management especially challenging in emerging nations. Guidelines have therefore emphasised antibiotic prophylaxis against recurrent episodes of acute rheumatic fever, which seems feasible and cost effective. Early detection and targeted treatment might be possible if populations at risk for rheumatic heart disease in endemic areas are screened. In this setting, active surveillance with echocardiography-based screening might become very important. Copyright © 2012 Elsevier Ltd. All rights reserved.
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              Characteristics, complications, and gaps in evidence-based interventions in rheumatic heart disease: the Global Rheumatic Heart Disease Registry (the REMEDY study).

              Rheumatic heart disease (RHD) accounts for over a million premature deaths annually; however, there is little contemporary information on presentation, complications, and treatment.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS Negl Trop Dis
                PLoS Negl Trop Dis
                plos
                plosntds
                PLoS Neglected Tropical Diseases
                Public Library of Science (San Francisco, CA USA )
                1935-2727
                1935-2735
                11 August 2016
                August 2016
                : 10
                : 8
                : e0004860
                Affiliations
                [1 ]Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
                [2 ]Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
                [3 ]Department of Global Health, University of Washington, Seattle, Washington, United States of America
                [4 ]Department of Pharmacy, University of Washington, Seattle, Washington, United States of America
                George Washington University, UNITED STATES
                Author notes

                The authors have declared that no competing interests exist.

                Conceived and designed the experiments: DW BM JBB. Performed the experiments: DW SJL. Analyzed the data: DW SJL BM JBB. Contributed reagents/materials/analysis tools: SJL. Wrote the paper: DW.

                Author information
                http://orcid.org/0000-0001-6341-9595
                Article
                PNTD-D-16-00592
                10.1371/journal.pntd.0004860
                4981376
                27512994
                84418081-3513-4d46-8265-1dba31483d81
                © 2016 Watkins et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 4 April 2016
                : 29 June 2016
                Page count
                Figures: 3, Tables: 3, Pages: 15
                Funding
                DW received support for this work through the RHD Action grant from Medtronic Foundation to RhEACH.
                Categories
                Research Article
                Medicine and Health Sciences
                Cardiovascular Medicine
                Cardiovascular Diseases
                Social Sciences
                Economics
                Economic Analysis
                Cost-Effectiveness Analysis
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Social Sciences
                Economics
                Health Economics
                Medicine and Health Sciences
                Health Care
                Health Economics
                People and Places
                Demography
                Death Rates
                Biology and Life Sciences
                Population Biology
                Population Metrics
                Death Rates
                Medicine and Health Sciences
                Public and Occupational Health
                Global Health
                People and Places
                Geographical Locations
                Africa
                Social Sciences
                Economics
                Economic Analysis
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

                Infectious disease & Microbiology
                Infectious disease & Microbiology

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