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      A systematic review of economic evaluations of interventions to tackle cardiovascular disease in low- and middle-income countries

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      1 , 2 , 3 , , 1 , 2 , 4
      BMC Public Health
      BioMed Central

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          Abstract

          Background

          Low-and middle-income countries are facing both a mounting burden of cardiovascular disease (CVD) as well as severe resource constraints that keep them from emulating some of the extensive strategies pursued in high-income countries. There is thus an urgency to identify and implement those interventions that help reap the biggest reductions of the CVD burden, given low resource levels. What are the interventions to combat CVDs that represent good "value for money" in low-and middle-income countries? This study reviews the evidence-base on economic evaluations of interventions located in those countries.

          Methods

          We conducted a systematic literature review of journal articles published until 2009, based on a comprehensive key-word based search in generic and specialized electronic databases, accompanied by manual searches of expert databases. The search strategy consisted of freetext and MeSH terms related to economic evaluation and cardiovascular disease. Two independent reviewers verified fulfillment of inclusion criteria and extracted study characteristics.

          Results

          Thirty-three studies met the selection criteria. We find a growing research interest, in particular in most recent years, if from a very low baseline. Most interventions fall under the category primary prevention, as opposed to case management or secondary prevention. Across the spectrum of interventions, pharmaceutical strategies have been the predominant focus, and, taken at face value, these show significant positive economic evidence, specifically when compared to the counterfactual of no interventions. Only a few studies consider non-clinical interventions, at population level. Almost half of the studies have modelled the intervention effectiveness based on existing risk-factor information and effectiveness evidence from high-income countries.

          Conclusion

          The cost-effectiveness evidence on CVD interventions in developing countries is growing, but remains scarce, and is biased towards pharmaceutical interventions. While the burden of cardiovascular disease is growing in these countries, future research should put greater emphasis on non-clinical interventions than has hitherto been the case. Significant differences in outcome measures and methodologies prohibit a direct ranking of the interventions by their degree of cost-effectiveness. Considerable caution should be exercised when transferring effectiveness estimates from developed countries for the purpose of modelling cost-effectiveness in developing countries. New local CVD risk factor and intervention follow-up studies are needed. Some pharmaceutical strategies appear cost-effective while clarifications are needed on the diagnostic approach in single high-risk factor vs. absolute risk targeting, the role of patient compliance, and the potential public health consequences of large-scale medicalization.

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          Most cited references28

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          Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.

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            Emerging epidemic of cardiovascular disease in developing countries.

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              Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000.

              Coronary heart disease mortality rates have been decreasing in the United Kingdom since the 1970s. Our study aimed to examine how much of the decrease in England and Wales between 1981 and 2000 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors. The IMPACT mortality model was used to combine and analyze data on uptake and effectiveness of cardiological treatments and risk factor trends in England and Wales. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and national surveys. Between 1981 and 2000, coronary heart disease mortality rates in England and Wales decreased by 62% in men and 45% in women 25 to 84 years old. This resulted in 68 230 fewer deaths in 2000. Some 42% of this decrease was attributed to treatments in individuals (including 11% to secondary prevention, 13% to heart failure treatments, 8% to initial treatments of acute myocardial infarction, and 3% to hypertension treatments) and 58% to population risk factor reductions (principally smoking, 48%; blood pressure, 9.5%; and cholesterol, 9.5%). Adverse trends were seen for physical activity, obesity and diabetes. More than half the coronary heart disease mortality decrease in Britain between 1981 and 2000 was attributable to reductions in major risk factors, principally smoking. This emphasizes the importance of a comprehensive strategy that promotes primary prevention, particularly for tobacco and diet, and that maximizes population coverage of effective treatments, especially for secondary prevention and heart failure. These findings may be cautiously generalizable to the United States and other developed countries.
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2012
                3 January 2012
                : 12
                : 2
                Affiliations
                [1 ]Norwich School of Medicine, University of East Anglia, Norwich NR4 7TJ, UK
                [2 ]UKCRC Centre for Diet and Activity Research (CEDAR), Robinson Way, Cambridge CB2 0SR, UK
                [3 ]Department of Medicine, University of Witten/Herdecke, Faculty of Health, Alfred-Herrhausen-Str. 50, 58448 Witten, Germany
                [4 ]Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, USA
                Article
                1471-2458-12-2
                10.1186/1471-2458-12-2
                3299641
                22214510
                fb3abc19-94bc-4d05-841c-855b306e1d19
                Copyright ©2011 Suhrcke et al; licensee 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 original work is properly cited.

                History
                : 4 July 2011
                : 3 January 2012
                Categories
                Research Article

                Public health
                Public health

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