7
Making Choices to Reduce the Burden of Cardiovascular Disease

It is clear from preceding chapters that the health and economic burden of cardiovascular disease (CVD) is high. This burden is likely to rise and remain unacceptably high in developing countries unless bold moves are made to implement policies and programs to contain the growth in prevalence of CVD and other chronic diseases, to develop and implement affordable and accessible health services and technology, and to reduce the financial risks to individuals and economies.

Aggressively reducing population and individual CVD risks would not only help low and middle income countries avert a potential crisis by reducing their chronic disease burden, it could also be viewed as an opportunity to improve both their economies and their public health. However, many developing countries face a difficult challenge: to make further headway against infectious diseases and other health concerns where they remain rampant while transforming health systems to accomplish chronic disease prevention and care. Very limited resources are available for health in developing countries, and there are great gaps in meeting needs. Therefore, the strategy in developing countries should be to seek low-cost approaches with a high potential return on investment to achieve structural and behavioral changes to reduce risk, and low-cost technology and health delivery to effectively treat and manage CVD.

There is a particular urgency to the need to identify and implement those interventions that can reap the biggest CVD reduction benefits in low and middle income countries while at the same time offering good “value for money.” Many of these countries are confronting a mounting gap between the dual disease burden they experience and the ability of



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7 Making Choices to Reduce the Burden of Cardiovascular Disease I t is clear from preceding chapters that the health and economic burden of cardiovascular disease (CVD) is high. This burden is likely to rise and remain unacceptably high in developing countries unless bold moves are made to implement policies and programs to contain the growth in prevalence of CVD and other chronic diseases, to develop and implement affordable and accessible health services and technology, and to reduce the financial risks to individuals and economies. Aggressively reducing population and individual CVD risks would not only help low and middle income countries avert a potential crisis by reduc- ing their chronic disease burden, it could also be viewed as an opportunity to improve both their economies and their public health. However, many developing countries face a difficult challenge: to make further headway against infectious diseases and other health concerns where they remain rampant while transforming health systems to accomplish chronic disease prevention and care. Very limited resources are available for health in de- veloping countries, and there are great gaps in meeting needs. Therefore, the strategy in developing countries should be to seek low-cost approaches with a high potential return on investment to achieve structural and behavioral changes to reduce risk, and low-cost technology and health delivery to ef- fectively treat and manage CVD. There is a particular urgency to the need to identify and implement those interventions that can reap the biggest CVD reduction benefits in low and middle income countries while at the same time offering good “value for money.” Many of these countries are confronting a mounting gap between the dual disease burden they experience and the ability of 

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD their health systems to deliver adequate care. Other countries are making headway as they and/or donors increase resource allocations to health. In both instances, informed choices about what the available resources will buy can better align needed and realized health improvements. ECONOMIC INFORMATION TO HELP ALLOCATE RESOURCES Economic measurements and analysis are critically important to inform decisions both about allocating resources and choosing among alternative solutions to the problem within and beyond the health sector. The health economics literature relies almost exclusively on cost-effectiveness measures to assess value for money. Cost-effectiveness analysis of interventions can be an important tool for choosing among interventions targeted to the same outcomes, and the first section of this chapter summarizes the available cost-effectiveness evidence for CVD interventions in low and middle income countries. However, cost-effectiveness provides little information about the affordability of given interventions or the actual value to the beneficiaries, and it does not allow for ready comparisons of interventions across differ- ent sectors and different health and development priorities. The potential return on investment needs to be assessed within a broad socioeconomic context, and guidance derived from cost-effectiveness analysis may be su- perseded by broader policy choices for allocating resources across compet- ing priorities within the parameters that society sets for achieving better health and well-being. Economic benefit–cost analysis can be used to bal- ance tradeoffs in choosing among alternatives, such as new technologies or investments in structural and policy changes. However, the analytical and data demands are much higher, and there are almost no cost–benefit studies available from developing countries on CVD interventions. Ultimately, deci- sions about how to prioritize investments will necessitate carefully defining feasible options for change and determining the willingness of stakeholders to shift resources to implement those changes. Summary of Cost-Effectiveness Evidence1 The preceding chapters have provided a thorough summary of the relevant CVD interventions under consideration in low and middle income countries. This section discusses the available evidence on their cost-effectiveness, draw- ing primarily on two rapid reviews commissioned for this report, which built on and updated major recent efforts such as the Disease Control Priorities Project (DCP2) (Musgrove and Fox-Rushby, 2006) and the WHO initia- 1This section is based in part on papers written for the committee by Marc Suhrcke et al. and by Stephen Jan and Alison Hayes.

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 MAKING CHOICES TO REDUCE THE BURDEN tive on Choosing Interventions That are Cost-effective (CHOICE) (WHO, 2010).2 While there is a large body of evidence on the cost-effectiveness of CVD-related interventions in developed countries, this chapter considers only evidence with an explicit focus on low and middle income countries. Most of the available studies identified in the commissioned reviews were focused on clinical prevention strategies and case management for individuals, with far fewer studies on population-based prevention approaches. Overall, most studies in both of these categories focused on risk-factor reduction. About half the economic studies relied on modeling analysis using es- timated cost assumptions and secondary data for intervention effectiveness and epidemiological conditions rather than on primary empirical data on costs and effectiveness from observational trials or randomized controlled trials in the setting of interest. In these models, developing-country data was the source for most of the epidemiological data, but developed countries were the source of data for intervention effectiveness. The advantages and limitations of these secondary versus primary analyses will be discussed further in the final section of this chapter on future research needs. It is also important to note that cost-effectiveness studies are difficult to compare because the threshold of what is considered cost-effective var- ies (the standard is 3× the per capita gross domestic product [GDP] for the country, but 1× GDP is sometimes used). In addition, the outcome measures and comparator are often not the same across studies (the stan- dard comparator is either no intervention or current standard care in the country). Different approaches for economic evaluation are also used, as well as different measures to express cost-effectiveness (the standard is an incremental cost-effectiveness ratio [ICER] reporting the cost per averted disability-adjusted life year [DALY] or quality-adjusted life year [QALY], but an average cost-effectiveness ratio [CER] is also used). Cost-Effectiveness of Population-Based and Other Lifestyle Interventions Population-based and other public health interventions typically tar- get nutrition, physical activity, and tobacco risk-factor reduction. There has been remarkably little research on non-clinical, population-based ap- proaches, such as legislative actions, education campaigns, or health pro- motion through social marketing, as a way to tackle CVD in developing 2 Searches were conducted using the PubMed and EconLit databases. In addition, the refer- ences of retrieved articles and the relevant publications of the DCP2 and the WHO CHOICE program were hand-searched for relevant articles. The search strategy consisted of freetext and MeSH terms related to economic evaluation and CVD disease or risk factors endpoints, filtered for the occurrence of the term “developing countries” or any country name defined as middle or low income country according to the World Bank definition. Only published full economic evaluations were included.

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0 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD countries. Changes in health policy are beginning to be observed in devel- oped countries such as the United Kingdom, Finland, and the United States. New strategies are being implemented, such as legislation for salt reduction and labeling of food (Karppanen and Mervaala, 2006), and some analysis has been done about the potential revenue and dietary benefits of taxes on sugared drinks and junk food (Brownell and Frieden, 2009) as well as the potential cost-effectiveness of community-based physical activity programs in the United States (Roux et al., 2008). However, most of these strategies have yet to be implemented with a rigorous economic evaluation component. In addition, since interventions targeted to change health behaviors are highly dependent on political, cultural, infrastructural, and other system-related aspects, it is deemed less feasible to assume effectiveness results from studies in developed regions can be applied to developing regions than is commonly accepted for clinical effectiveness evidence (Jamison et al., 2006). In pharmaceutical research, for example, a common assumption is that a drug affecting biomedical processes would have approximately identical effects, irrespective of the context in which it is applied. This is less likely to be the case for a health communication campaign or for legislative or regulatory approaches. Nonetheless, evidence from both modeling and some primary economic analysis is building that population-level interventions targeted to reduce CVD are likely to be cost-effective in low and middle income countries. Table 7.5a at the end of this chapter summarizes the cost-effectiveness results for population-based CVD interventions in a developing-country setting. The antitobacco regulatory interventions, such as taxation, smoke-free public places, restrictions on marketing, and youth cessation are strongly supported. In particular, taxation and legislation options have been rela- tively well evaluated, certainly for developed regions and countries but also for developing-country settings (Chisholm et al., 2006). Those include reviews such as an article by Shibuya et al. (2003) and the Disease Control Priorities in Developing Countries publication (Jha et al., 2006), both of which describe an increase in tobacco tax as the most cost-effective strategy to reduce smoking prevalence, followed by comprehensive advertisement campaigns and bans on smoking in public places. Tobacco taxes combined with smoking and advertising bans is also cost-effective (Gaziano, 2008; Lai et al., 2007). A modeling study also showed cost savings from a com- munity-based pharmacist-driven education and counseling program for prevention of CVD risk from smoking among high-risk groups of men and women in Thailand (Thavorn and Chaiyakunapruk, 2008). A number of studies have found food regulation (including regulation of salt or substitution of transfats) to be highly cost-effective, even cost- saving. These studies included cooperation among government, industry, and consumer organizations to reduce the salt content in bread in Argentina

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 MAKING CHOICES TO REDUCE THE BURDEN (Rubinstein et al., 2009) and salt reduction in processed foods through industry agreements or legislation in South-East Asia, Latin America, and Sub-Saharan Africa (Gaziano, 2008; Murray et al., 2003). However, the few studies of this type that exist have not conducted a thorough examina- tion of the true costs of achieving policy or regulatory change, which can be high during the policy advocacy phase and then generally diminish. Promoting physical activity is a CVD prevention intervention that has been largely overlooked by economic evaluation. The Agita São Paulo pro- gram, described in Chapter 5, is known globally as an effective intervention to promote physical activity in Brazil. It was evaluated by the World Bank and also found to be cost-effective (Matsudo et al., 2006). In a more narrow approach, a randomized controlled trial of home-based physical activity education for rehabilitation of post-MI coronary patients in Brazil showed significant improvements in all domains at a low cost (Salvetti et al., 2008). Educational campaigns for outcomes beyond tobacco use are also shown as highly cost-effective in the few studies of this type (mainly ad- dressing high blood pressure, high cholesterol, and lowering body mass index [BMI]), and some are even cost-saving. Cost-effectiveness modeling of health education programs for multi-risk reduction in multiple regions demonstrated positive results (Murray et al., 2003). Salt reduction through communication and mass media programs were deemed likely to be cost- effective, as well as similar programs for tobacco control, in a range of low and middle income countries at about $0.40 per person per day (Asaria et al., 2007). A population-based social marketing study with experimental and control groups in Thailand shows effective hypertension risk reduction at very low cost when village health workers were mobilized with trained health workers (Getpreechaswas et al., 2007). Bi-weekly home counseling visits by a trained health professional in Mexico were also very cost-effective in reducing hypertension (García-Peña et al., 2002). A community-based primary prevention program in Beijing to alter food intake also showed cost savings (Huang et al., 2001). However, the reported ICERs for health edu- cation interventions were quite variable. This suggests a degree of variation and uncertainty in the parameters used for such studies. It is also difficult to judge the effects of mass education programs due to difficulties in assessing numbers of persons reached. In summary, legislated reductions in salt and transfats in foods, tobacco taxation and restrictions, and health education campaigns all show some promising cost-effectiveness across a range of countries. However, except for antitobacco measures in developed countries, the cost-effectiveness of population-based interventions has been measured almost entirely through modeling techniques. These few studies are generally supportive of one another, but need confirmation from a broad range of empirical examples using primary data.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD Cost-Effectiveness of Pharmaceutical and Other Clinical Interventions Cost-effectiveness results for pharmaceutical and other clinical interven- tions for CVD in a developing-country setting are summarized in Table 7.5b at the end of this chapter. These strategies have been the predominant focus of economic analysis to date. In summary, the cost-effectiveness of pharma- ceutical interventions to reduce CVD depends heavily on the risk group tar- geted. Prevention with pharmacological treatment for high-risk individuals is likely to be cost-effective across a range of country settings. Prevention with pharmacological treatment is not generally likely to be cost-effective for reducing risk factors in individuals without high absolute risk. In conclusion, just as with the available intervention effectiveness re- viewed in Chapter 5, there are limitations on the available economic analy- ses. These limitations guide future needs, which will be discussed later in this chapter. However, they do not preclude intervening now, and some determinations can be made about priorities for investment in interven- tion approaches. Indeed, both intervention and economic evidence support selected population-based interventions and pharmacological interventions for high-risk target groups to reduce CVD and hypertension. Although there are interventions that are likely to be cost-effective, it remains dif- ficult to make comparisons to draw definitive conclusions about which interventions are the most cost-effective. This is both due to the challenges of making comparisons across the available studies and due to gaps in the economic evaluation literature in some important areas of intervention that have promise for effective impact on health outcomes. Economic Information to Compare Prevention and Treatment Strategies When comparing interventions to reduce the burden of CVD, it is tempting to try to look to the economic analysis to make a determination about whether it would be more advisable to invest in prevention strategies or treatment strategies. To many, prevention seems like the most promis- ing investment because of its potential for avoidance of costly treatment interventions (technology, hospitalization, etc.). On the other hand, many see potential for a high return on investment in terms of health outcomes from advances in technology and health services if made more available in the developing world. The evidence does not provide a definitive choice between prevention and treatment on economic grounds. There is economic evidence to support the cost-effectiveness of implementation on a wider scale of certain pharma- ceutical strategies in developing countries (Gaziano et al., 2007). However, the issue of how best to approach implementation remains unresolved (Gaziano, 2007), which was also a central message of Chapter 5. There is

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 MAKING CHOICES TO REDUCE THE BURDEN also an unresolved discussion between those who advocate for the target- ing of patients with a single but high-risk factor (e.g., high blood pressure) and those arguing for an overall absolute risk approach (e.g., on the basis of 10-year risk of CVD), independent from the particular risk factor. These are debates on medical effectiveness, but they also spill over into the eco- nomic evaluation literature, as evidenced by the differences in therapeutic combinations and assessments of patient risks across the cost-effectiveness studies summarized in Table 7.5b at the end of this chapter. In addition, there has been limited economic evaluation of screening strategies, a nec- essary component of scaling up interventions to target individuals at high risk that is certainly not without cost. Therefore, considering the potential costs of scaling up and screening for risk factors as well as for delivering adequate supplies of drugs for persons identified through screening, there is still room for debate about whether pharmaceutical interventions are the right priority. In addition, factors such as the risk of adverse events in such a large untreated population, inequalities in access to care, and limited patient and system compliance need to be addressed. Despite a general endorsement of scaling up pharmaceutical support from the economic perspective, it is also important to be mindful of the limitations of a strategy focused narrowly on pharmaceutical support. Clinically managed chronic care can be expensive and is often necessary for the remaining lifetime of an individual. In addition, clincial approaches tar- geted at segments of the population with higher risk (e.g., based on blood pressure) miss the typically large number of people below the threshold but nevertheless with risk factor-related ailments (Blackburn, 1983; Kottke et al., 1985; Puska et al., 1985; Schooler et al., 1997). A population-based approach, like one aiming for a reduction in salt intake, would at least in principle effect change in the entire population and not only those in the population at the highest risk, and in principle over the long term this could reduce the ultimate need for costly clinical interventions. This may render such population-based approaches attractive because of the rationale for a likelihood of cost-effectiveness over time, although the population risk reduction with these approaches can be limited (Neal et al., 2007). In reality, the issue of prevention versus treatment is probably not the most useful question. The epidemic of CVD is not going to be addressed through the eradication of the disease in an entire population, the way one might hope to eradicate a disease with an acute infectious etiology. Instead, the goals for reducing the population burden of disease are that a greater proportion of the population can avoid developing the disease, that the average age of onset can be delayed, and that morbidity, mortality, and financial consequences due to CVD can be reduced. Indeed, the total- ity of the available epidemiological, intervention, and economic evidence support a balanced approach in which health promotion and prevention is

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD emphasized but which also recognizes the need for effective, appropriate, quality delivery of medical interventions for risk reduction and treatment. The distribution of investment in health promotion, prevention, and treat- ment approaches within that balance is something that will need to be determined based on the specific needs, capacity, and political and societal will of the stakeholder making the investment. The potential for improving the information available to inform this decision making is described in the final section of this chapter. Costs to Address Gaps in CVD Needs3 One of the key questions asked by policy makers wishing to make in- vestments to address an unmet health need is, “What will it cost?” The total cost to reduce the burden of disease is determined not only by the costs of interventions but also by the number of affected people in need of them. The difference between the proportion of the population that could benefit from intervention and that currently receiving such intervention is commonly called the “treatment gap.” This treatment gap can be defined in terms of any intervention approach, including population-based approaches and individual prevention or treatment. Determining the treatment gap depends on knowing four key parameters: prevalence in the population of a health condition; proportion of people with the condition that are treated and, conversely, the proportion that are not; proportion with the condition under control and, conversely the proportion not controlled; and cost of treat- ment. It is generally recognized that, particularly in developing countries, there are significant numbers of individuals who are in need but have not benefited from potentially effective and cost-effective interventions to treat or reduce risk for CVD and related chronic diseases. However, this treatment gap would need to be more specifically defined and linked to accurate cost information in order to more precisely determine the investment that would be required. This section of the chapter offers a discussion of illustrative evidence to demonstrate the analytic approaches available to determine what it will cost to reduce the burden of CVD in developing countries. A short review was commissioned for this report of the treatment gaps in the developing world for CVD and related risk factors (Jan and Hayes, 2009).4 The objective of the review was to assess the feasibility of an ap- proach to investment appraisal that brings together two sources of data: 3 This section is based in part on papers written for the committee by Stephen Jan and Alison Hayes and by Thomas Gaziano and Grace Kim. 4 The authors conducted a non-systematic search of the published and grey literature us- ing PubMed and Google Scholar databases as well as hand-searches and snowballing. Search terms included “treatment gap and chronic diseases” and “treatment gap and cardiovascular disease.”

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 MAKING CHOICES TO REDUCE THE BURDEN the nature and the scale of treatment gaps in CVD in developing countries and the costs and cost-effectiveness of a range of interventions. The review extracted evidence on treatment gaps from systematic reviews of treatment gaps for hypertension, comparative studies of risk reduction in individuals with CVD, and numerous studies of treatment gaps for specific diseases and risk factors in individual countries. A fair degree of standardization in the approaches taken to measuring treatment gaps enables some comparisons to be made across studies, but the appropriateness of generalizations about average overall rates is limited because the studies are derived from multiple sources across different settings and involve varying methodologies. In ad- dition, although the available evidence establishes the treatment gap for some risk factors related to CVD, there remain methodological problems that make it difficult to reliably link the current evidence on treatment gaps with the current evidence on costs and cost-effectiveness in order to deter- mine the total investment required to fill the treatment gap. The studies extracted in this review provided sufficient information to assess treatment gaps in some countries for some risk factors for CVD, including hypertension, high cholesterol, and diabetes as well as ongoing risk reduction in individuals with CVD. The results show large treatment gaps. For other risk factors, such as obesity, lack of physical activity, and tobacco use, there is sufficient data to derive population estimates that in- dicate the potential numbers of individuals who could benefit from added intervention but not sufficient data on the numbers receiving interventions to determine a treatment gap. For hypertension, a number of recent studies indicate that hypertension prevalence is on average around 30 percent of the adult population in devel- oping countries, with a wide variation across settings, from 5 percent in rural India to 70 percent in Poland (Kearney et al., 2004). The available evidence indicates that around 30 percent of individuals with reported hypertension across developing countries are receiving treatment—thus a 70 percent treat- ment gap (Pereira et al., 2009). This gap varies not only across countries but also over time. For example, evidence from China indicates treatment levels at 17 percent in urban populations and 5 percent in rural populations in 1991 (Whelton et al., 2004), but levels were more recently observed at 28.2 percent overall in 2000-2001 (Gu et al., 2002). These variations demonstrate the dif- ficulties with generalizing over time and across countries that are at differing stages of epidemiological and economic transition. An interesting finding from the studies reviewed is that even in countries with relatively high proportions of patients getting treatment, the percent of hypertension under control is sometimes low. Across countries, around 30 percent of those receiving treatment in developing countries have their hy- pertension under control, which is similar to the rate of around 35 percent that has been observed in developed countries (Pereira et al., 2009).

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD Although most studies review gaps in treatment using pharmaceutical interventions to reduce hypertension, recent evidence from China through the InterASIA study sheds some light on treatment coverage for nonphar- macotherapies. This study found that 47.2 percent of people with hyper- tension were using at least one of five nonpharmacological approaches, including salt reduction, weight loss or weight control therapies, exercise, alcohol reduction, and potassium supplementation at the time of the survey (Gu et al., 2002). For cholesterol and diabetes, data is much less available than for hyper- tension. Evidence for both derives mainly from recent systematic reviews in China. The prevalence of moderate hypercholesterolemia (defined as ≥ 200 mg/dl total cholesterol) was 32.8 percent and the prevalence of high hyper- cholesterolemia (defined as ≥ 240 mg/dl total cholesterol or taking cholesterol lowering medications) was 9.0 percent. For those with moderately high cho- lesterol levels, 3.5 percent of men and 3.4 percent of women were receiving treatment, while 14 percent of men and 11.6 percent of women with very high cholesterol levels were receiving treatment. This suggests significant treatment gaps as high as 96 percent or 86 percent, depending on the criteria used for treatment (He et al., 2004). The prevalence of diabetes in China is around 5 percent, but only 20.3 percent are currently on treatment and 8.3 percent report being able to achieve control (Hu et al., 2008). A study based on the WHO Study on Prevention of Recurrences of Myocardial Infarction and Stroke (PREMISE) project examined the level at which patients already diagnosed with coronary heart disease or cerebrovas- cular disease are being treated for ongoing risk-factor reduction. This study was conducted across 10 countries (Brazil, Egypt, India, Indonesia, Iran, Pakistan, Russia, Sri Lanka, Tunisia, and Turkey) and assessed patients’ awareness and uptake of lifestyle and pharmacological interventions (Mendis et al., 2005). Table 7.1a shows the percentage of patients with coronary heart disease and cerbrovascular disease on pharmaceutical interventions for risk reduction. For both conditions, the levels of medication use are highest for aspirin and lowest for statins. Also, although there was a high level of aware- ness of the benefits of various lifestyle interventions, uptake of these interven- tions was variable (Table 7.1b). Looking at a country-specific analysis, India was quite similar to the overall findings in terms of pharmaceutical interven- tions (Table 7.1c). However, another study in rural India showed much lower levels of patients on medication antiplatelet therapy, blood pressure-lowering drugs, and statins (Joshi et al., 2009) (Table 7.1d). Estimated Costs to Fill the Hypertension Treatment Gap in 0 Countries In addition to the review of the available literature described earlier, a modeling analysis of treatment gaps for hypertension and costs to achieve

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 MAKING CHOICES TO REDUCE THE BURDEN TABLE 7.1a Patients on Medications in 10 Low and Middle Income Countries Coronary Heart Disease Cerebrovascular Disease Aspirin 81.2% 70.5% Beta-Blocker 48.1% 22.1% ACE-Inhibitor 39.8% 38.1% Statin 29.8% 12.2% NOTE: WHO PREMISE data from Brazil, Egypt, India, Indonesia, Iran, Pakistan, Russia, Sri Lanka, Tunisia, and Turkey. SOURCE: Mendis et al., 2005. TABLE 7.1b Awareness and Uptake of Lifestyle Interventions in Patients in 10 Low and Middle Income Countries Awareness of Benefits Behavior Smoking Cessation 82% 12% tobacco users Healthful Diet 89% 35% did not follow healthful diet Physical Activity 77% 52.5% less than 30 mins exercise/day NOTE: WHO PREMISE data from Brazil, Egypt, India, Indonesia, Iran, Pakistan, Russia, Sri Lanka, Tunisia, and Turkey. SOURCE: Mendis et al., 2005. TABLE 7.1c Patients on Medications in India Coronary Heart Disease Cerebrovascular Disease Aspirin 94.5% 90.1% Beta-Blocker 46.2% 28.4% ACE-Inhibitor 41.3% 23.5% Statin 38.4% 37.0% NOTE: WHO PREMISE data from India. SOURCE: Mendis et al., 2005. TABLE 7.1d Patients on Medications in Rural India Coronary Heart Disease Stroke Antiplatelet (aspirin, copidogrel) 19.4% 11.8% Blood Pressure-Lowering (beta-blocker, 41.1% 53.9% ACE-Inhibitor, diuretic, and others) Statin 6.0% 1.0% SOURCE: Joshi et al., 2009.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD TABLE 7.5b Continued Intervention Country/ Type Reference Setting Intervention Comparator Pharmaceutical Edwards et al., South Africa Reducing availability Current (cont.) 1998 for routine prescribing drug of less cost-effective treatment antihypertensive drugs or drug combinations Oyewo, 1989 Nigeria Treatment of Respective hypertension with alternative antihypertensives drug Treatment and Prevention of Cardiac Events Use of β-blocker or Biccard et al., South Africa Placebo 2006 statin following surgery to avoid cardiovascular complications in patients with >10% risk Orlewska et Poland Treatment with al., 2003 enoxaparin in acute coronary syndrome

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 MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis Cost- Methodologya Assumed Outcomea Resulta Effective? Observational Observed blood pressure Monthly cost per patient Not trial control did not change decreased 24.2% due to applicable decrease in prescriptions of less cost-effective drugs for more cost- effective drugs Cross-sectional Efficacy coded based on Effectiveness score/ See systolic blood pressure average monthly cost comparison reduction observed Thiazide 0.49 result Mean values of coding Thiazide and Thiazide 2.94 methyldopa 0.27 Thiazide and methyldopa 4.05 Thiazide,mMethyldopa, Thiazide, methyldopa, and and hydralazine 0.18 hydralazine 4.95 Propranolol 0.26 Propranolol 3.10 Propranolol and Propranolol and thiazide 2.53 thiazide 0.14 Brinerdine 3.20 Brinerdine 0.21 Minizide 1.30 Minizide 0.06 Assumed the use of β-blockers Peri-operative β-blocker Modeling Not reported reduced the risk of non-fatal therapy may potentially CVD events from 7.7% to save R869 per patient, 4% and risk of death from statin treatment R1,822 8.2% to 4.2% but increased per patient the risk of adverse events from 33.8% to 49.2% Assumed the use of statins reduced the risk of non-fatal CVD events from 11.3% to 6.5% and risk of death from 4% to 2.2% Modeling Assumed a 19.8% 30-day Cost/patient of See event (MI, recurrent angina, enoxaparin = Z1085; comparison or death) rate for those using cost/patient of UFH = result enoxaparin and a 23.3% 30- Z1097 day event rate for those using UFH continued

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD TABLE 7.5b Continued Intervention Country/ Type Reference Setting Intervention Comparator Treatment and Araujo et al., Brazil Pre-hospital In-hospital Prevention of 2008 thrombolysis in acute Cardiac Events MI (cont.) Rodriguez et Argentina Percutaneous Coronary al., 1993 transluminal coronary artery angioplasty (PTCA) bypass graft (CABG) surgery Grines et al., Multi-national: Early discharge after Traditional 1998 (developed and primary angioplasty in Care developing low-risk patients after nations) acute MI Health Care Delivery Diaz et al., Chile Stroke unit Regular 2006 hospital care

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 MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis Cost- Methodologya Assumed Outcomea Resulta Effective? Modeling Assumed a gain of .1585 life Dominated See years over 20 years with use Pre-hospital thrombolysis comparison of pre-hospital thrombolysis cost R$176 less per result versus in-hospital .1585 life year gained thrombolysis (over 20 years) RCT In-hospital complication rate Cumulative (group) costs Not reported for PTCA was death 1.5%, at 1-year: AMI 6.3%, emergency CABG PTCA (US$438,000), 1.5%, and stroke 1.5% CABG (US$828,000) In-hospital complication rate for CABG was death 4.6%, AMI 6.2%, emergency PTCA 1.5%, stroke 3.1% RCT Rates of readmission in Early discharge patients Not reported early discharge patients were had significantly lower 4.2% for recurrent unstable hospital costs (US$9,658 ischemia or MI, target vessel +/–5,287) compared revascularization 9.8%, death to traditional care 0.8%, reinfarction 0.8%, (US$11,604 +/–6,125) unstable ischemia 10.1%, stoke 0.4%, CHF 4.6%, and any event 15.2% Rates of readmission in traditional care patients were 3.9% for recurrent unstable ischemia or MI, target vessel revascularization 8.6%, death 0.4%, reinfarction 0.4%, unstable ischemia 12.0%, stroke 2.6%, CHF 4.3%, and any event 17.5% Observational Stroke unit: Mean length of Stroke unit: Mean cost Not reported trial stay: 6.6 days per patient: US$5.550; Hospital: Mean length of stay: Hospital: Mean cost per 9.9 days patient US$4.815 continued

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD TABLE 7.5b Continued Intervention Country/ Type Reference Setting Intervention Comparator Health Care Pannarunothai Thailand Health care delivery Healthcare Delivery et al., 2001 by urban health center delivery by (cont.) for hypertension and home visit diabetes program at the regional hospital and no home visit program Hauswald and Malaysia EMS system to treat Current Yeoh, 1997 acute MI care (performed by police/ private vehicle) NOTE: ACE-inhibitor = Angiotensin converting enzyme inhibitor; AMI = Acute Myocardial Infarction; CABG = Coronary Artery Bypass Graft; CBV = Cerebrovascular; CER = Cost- Effectiveness Ratio; CHD = Coronary Heart Disease; CHF = Congestive Heart Failure; CVD = Cardiovascular Disease; DALY = Disability-Adjusted Life Year; GDP = Gross Domestic Product; GNI = Gross National Income; ICER = Incremental Cost-Effectiveness Ratio; MI = Myocardial Infarction; PTCA = Percutaneous Transluminal Coronary Angioplasty; QALY = Quality-Adjusted Life Year; RCT = Randomized Controlled Trial; SBP = Systolic Blood Pressure; SDBP = Sitting Diastolic Blood Pressure; UFH = Unfractionated Heparin; WHO = World Health Organization.

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 MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis Cost- Methodologya Assumed Outcomea Resulta Effective? Retrospective Identified the % of patients Total costs per % of See analysis with controlled hypertension patients with controlled comparison (SBP <160mmHg) was disease result 79.4% at the urban health center, 72.8% at the Maharaj Hypertension: Hospital, and 79.8% of Urban health center 5729 people receiving no home visit baht care Maharaj Hospital home visit 7137 baht Identified the % of patients No home visit 7195 baht with controlled diabetes (fasting blood sugar 80- Diabetes: 140mg/dl) was 50% at the Urban health center 7468 urban health center, 49% at baht the Maharaj Hospital, and Maharaj Hospital home 33% of people receiving no visit 12313 baht home visit care No home visit 17861baht Modeling Assumed delivery of a Pre-hospital system for Not reported defibrillator to 85% of Kuala Lumpur would patients in less than 6 minutes cost approximately and a 6% increase in survival US$357,000 per life rate from pre-hospital saved with approximately defibrillation with 50% 40% having significant having significant neurologic neurological damage injury

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD REFERENCES Amira, O., and N. Okubadejo. 2007. Frequency of complementary and alternative medicine utilization in hypertensive patients attending an urban tertiary care centre in Nigeria. BMC Complementary and Alternative Medicine 7(1):30. Anderson, A. N., F. Wessels, I. Moodley, and K. Kropman. 2000. At1 receptor blockers— cost-effectiveness within the South African context. South African Medical Journal 90(5):494-498. Araujo, D. V., B. R. Tura, A. L. Brasileiro, H. Luz Neto, A. L. Pavao, and V. Teich. 2008. Cost- effectiveness of prehospital versus inhospital thrombolysis in acute myocardial infarction. Arquivos Brasileiros de Cardiologia 90(2):91-98. Asaria, P., D. Chisholm, C. Mathers, M. Ezzati, and R. Beaglehole. 2007. Chronic disease pre- vention: Health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet 370(9604):2044-2053. Behrman, J. R., J. A. Behrman, and N. M. Perez. 2009. On what diseases and health condi- tions should new economic research on health and development focus? Health Economics 18(S1):S109-S128. Biccard, B. M., J. W. Sear, and P. Foex. 2006. The pharmaco-economics of peri-operative beta-blocker and statin therapy in South Africa. South African Medical Journal 96(11): 1199-1202. Blackburn, H. 1983. Research and demonstration projects in community cardiovascular dis- ease prevention. Journal of Public Health Policy 4(4):398-421. Brownell, K. D., and T. R. Frieden. 2009. Ounces of prevention: The public policy case for taxes on sugared beverages. New England Journal of Medicine 360(18):1805-1808. Chisholm, D., C. Doran, K. Shibuya, and J. R. Rehm. 2006. Comparative cost-effectiveness of policy instruments for reducing the global burden of alcohol, tobacco and illicit drug use. Drug and Alcohol Review 25(6):553-565. Dias da Costa, J. S., S. C. Fuchs, M. T. Olinto, D. P. Gigante, A. M. Menezes, S. Macedo, and S. Gehrke. 2002. Cost-effectiveness of hypertension treatment: A population-based study. São Paulo Medical Journal 120(4):100-104. Diaz, T. V., D. S. Illanes, M. A. Reccius, V. J. Manterola, C. P. Cerda, L. C. Recabarren, and V. R. Gonzalez. 2006. Evaluation of a stroke unit at a university hospital in Chile. Revista Médica de Chilé 134(11):1402-1408. Edwards, P. R., D. W. Lunt, G. S. Fehrsen, C. J. Lombard, and K. Steyn. 1998. Improving cost- effectiveness of hypertension management at a community health centre. South African Medical Journal 88(5):549-554. Evans, W. D., and A. Ulasevich. 2005. News media tracking of tobacco control: A review of sampling methodologies. Journal of Health Communication 10(5):403-417. Ford, E. S., and S. Capewell. 2007. Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: Concealed leveling of mortality rates. Journal of the American College of Cardiology 50(22):2128-2132. García-Peña, C., M. Thorogood, D. Wonderling, and S. Reyes-Frausto. 2002. Economic analysis of a pragmatic randomised trial of home visits by a nurse to elderly people with hypertension in Mexico. Salud Publica de Mexico 44:14-20. Gaziano, T. A. 2005. Cardiovascular disease in the developing world and its cost-effective management. Circulation 112(23):3547-3553. Gaziano, T. A. 2007. Reducing the growing burden of cardiovascular disease in the developing world. Health Affairs 26(1):13-24. Gaziano, T. A. 2008. Economic burden and the cost-effectiveness of treatment of cardiovas- cular diseases in Africa. Heart 94(2):140-144.

OCR for page 317
 MAKING CHOICES TO REDUCE THE BURDEN Gaziano, T., and G. I. Kim. 2009. Cost of treating non-optimal blood pressure in select low and middle income countries in comparison to the United States. Boston, MA: Back- ground Paper Commissioned by the Committee on Preventing the Global Epidemic of Cardiovascular Disease. Gaziano, T.A., L. H. Opie, and M. C. Weinstein. 2006. Cardiovascular disease prevention with a multidrug regimen in the developing world: A cost-effectiveness analysis. Lancet 368(9536):679-86. Gaziano, T. A., G. Galea, and K. S. Reddy. 2007. Chronic diseases II: Scaling up interventions for chronic disease prevention: The evidence. Lancet 370(9603):1939-1946. Gaziano, T. A., A. Bitton, S. Anand, M. C. Weinstein. 2009. The global cost of nonoptimal blood pressure. Journal of Hypertension 27(7):1472-1477. Getpreechaswas, J., N. Boontorterm, and P. Yospol. 2007. A model of health services for hypertension in primary care unit in Patumthani province. Journal of the Medical As- sociation of Thailand 90(1):129-136. Grines, C. L., D. L. Marsalese, B. Brodie, J. Griffin, B. Donohue, C. R. Costantini, C. Balestrini, G. Stone, T. Wharton, P. Esente, M. Spain, J. Moses, M. Nobuyoshi, M. Ayres, D. Jones, D. Mason, D. Sachs, L. L. Grines, and W. O’Neill. 1998. Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II investigators. Primary angioplasty in myocardial infarction. Journal of the American College of Cardiology 31(5):967-972. Gu, D., K. Reynolds, X. Wu, J. Chen, X. Duan, P. Muntner, G. Huang, R. F. Reynolds, S. Su, P. K. Whelton, and J. He. 2002. Prevalence, awareness, treatment, and control of hypertension in China. Hypertension 40(6):920-927. Hauswald, M., and E. Yeoh. 1997. Designing a prehospital system for a developing country: Estimated cost and benefits. American Journal of Emergency Medicine 15(6):600-603. He, J., D. Gu, K. Reynolds, X. Wu, P. Muntner, J. Zhao, J. Chen, D. Liu, J. Mo, and P. K. Whelton. 2004. Serum total and lipoprotein cholesterol levels and awareness, treatment, and control of hypercholesterolemia in China. Circulation 110(4):405-411. Hu, D., P. Fu, J. Xie, C. S. Chen, D. Yu, P. K. Whelton, et al. 2008. Increasing prevalence and low awareness, treatment and control of diabetes mellitus among Chinese adults: The InterASIA study. Diabetes Research and Clinical Practice 81(2):250-257. Huang, G. Y., D. F. Gu, X. F. Duan, X. S. Xu, W. Q. Gan, J. C. Chen, B. Y. Xie, and X. G. Wu. 2000. [effects of 8 years community intervention on risk factors of cardiovascular diseases in Fangshan Beijing]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 23(1):15-18. Jamison, D. T., J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills, and P. Musgrove, eds. 2006. Disease control priorities in developing countries. 2nd ed. New York: Oxford University Press. Jan, S., and A. Hayes. 2009 (unpublished). A review of the evidence on treatment gaps, costs and cost-effectiveness of interventions for the prevention of cardiovascular disease in developing countries. Jha, P., F. J. Chaloupka, J. Moore, V. Gajalakshmi, P. C. Gupta, R. Peck, S. Asma, and W. Zatonski. 2006. Tobacco addiction. In Disease control priorities in developing countries. 2nd ed. Edited by D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills and P. Musgrove. New York: Oxford University Press. Pp. 869-886. Joshi, R., C. K. Chow, P. K. Raju, R. Raju, K. S. Reddy, S. Macmahon, et al. 2009. Fatal and nonfatal cardiovascular disease and the use of therapies for secondary prevention in a rural region of India. Circulation 119(14):1950-1955. Karppanen, H., and E. Mervaala. 2006. Sodium intake and hypertension. Progress in Cardio- vascular Diseases 49(2):59-75.

OCR for page 317
0 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD Kearney, P. M., M. Whelton, K. Reynolds, P. K. Whelton, and J. He. 2004. Worldwide preva- lence of hypertension: A systematic review. Journal of Hypertension 22(1):11-19. Ker, J. A., H. Oosthuizen, and P. Rheeder. 2008. Decision-making using absolute cardiovascu- lar risk reduction and incremental cost-effectiveness ratios: A case study. Cardiovascular Journal of Africa 19(2):97-101. Kottke, T., P. Puska, J. T. Salonen, J. Tuomilehto, and A. Nissinen. 1985. Projected effects of high-risk versus population-based prevention strategies in coronary heart disease. American Journal of Epidemiology 121(5):697-704. Lai, T., J. Habicht, M. Reinap, D. Chisholm, and R. Baltussen. 2007. Costs, health effects and cost-effectiveness of alcohol and tobacco control strategies in Estonia. Health Policy 84(1):75-88. Lim, S. S., T. A. Gaziano, E. Gakidou, K. S. Reddy, F. Farzadfar, R. Lozano, and A. Rodgers. 2007. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: Health effects and costs. Lancet 370(9604):2054-2062. Manuel, D. G., J. Lim, P. Tanuseputro, G. M. Anderson, D. A. Alter, A. Laupacis, and C. A. Mustard. 2006. Revisiting rose: Strategies for reducing coronary heart disease. British Medical Journal 332(7542):659-662. Matsudo, S. M., V. K. R. Matsudo, D. R. Andrade, T. L. Araújo, and M. Pratt. 2006. Evalu- ation of a physical activity promotion program: The example of Agita São Paulo. Evalu- ation and Program Planning 29(3):301-311. Mendis, S., D. Abegunde, S. Yusuf, S. Ebrahim, G. Shaper, H. Ghannem, et al. 2005. WHO study on Prevention of REcurrences of Myocardial Infarction and StrokE (WHO- PREMISE). Bulletin of the World Health Organization 83(11):820-829. Moreira, G. C., J. P. Cipullo, J. F. Martin, L. A. Ciorlia, M. R. Godoy, C. B. Cesarino, et al. 2009. Evaluation of the awareness, control and cost-effectiveness of hypertension treat- ment in a Brazilian city: Populational study. Journal of Hypertension 27(9):1900-1907. Murray, C. J., J. A. Lauer, R. C. Hutubessy, L. Niessen, N. Tomijima, A. Rodgers, C. M. Lawes, and D. B. Evans. 2003. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: A global and regional analysis on reduction of cardio- vascular-disease risk. Lancet 361(9359):717-725. Musgrove, P., and J. Fox-Rushby. 2006. Cost-effectiveness analysis for priority setting. In Disease Control Priorities in Developing Countries. 2nd ed, edited by D. T. Jamison, J. G. Breman, A. R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills and P. Musgrove. New York: Oxford University Press. Pp. 271-286. Neal, B., W. Yangfeng, and N. Li. 2007. The effectiveness and costs of population interven- tions to reduce salt consumption. Geneva: World Health Organization. Orlewska, E., A. Budaj, and D. Tereszkowski-Kaminski. 2003. Cost-effectiveness analy- sis of enoxaparin versus unfractionated heparin in patients with acute coronary syn- drome in Poland: Modelling study from the hospital perspective. Pharmacoeconomics 21(10):737-748. Oyewo, E. A., A. A. Ajayi, and G. O. Ladipo. 1989. A therapeutic audit in the management of hypertension in Nigerians. East African Medical Journal 66(7):458-467. Pannarunothai, S., M. Kongpan, and R. Mangklasiri. 2001. Costs-effectiveness of the urban health center in Nakhon Ratchasima: A case study on diabetes and hypertension. Journal of the Medical Association of Thailand 84(8):1204-1211. Pereira, M., N. Lunet, A. Azevedo, and H. Barros. 2009. Differences in prevalence, aware- ness, treatment and control of hypertension between developing and developed countries. Journal of Hypertension 27(5):963-975.

OCR for page 317
 MAKING CHOICES TO REDUCE THE BURDEN Puska, P., A. Nissinen, J. Tuomilehto, J. T. Salonen, K. Koskela, A. McAlister, T. E. Kottke, N. Maccoby, and J. W. Farquhar. 1985. The community-based strategy to prevent coronary heart disease: conclusions from the ten years of the North Karelia project. Annual Review of Public Health 6:147-193. Ravishankar, N., P. Gubbins, R. J. Cooley, K. Leach-Kemon, C. M. Michaud, D. T. Jamison, and C. J. Murray. 2009. Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet 373(9681):2113-2124. Redekop, W. K., E. Orlewska, P. Maciejewski, F. F. Rutten, and L. W. Niessen. 2008. Costs and effects of secondary prevention with perindopril in stable coronary heart disease in Poland: An analysis of the Europa Study including 1251 Polish patients. Pharmacoeco- nomics 26(10):861-877. Robberstad, B., Y. Hemed, O. F. Norheim. 2007. Cost-effectiveness of medical interventions to prevent cardiovascular disease in a Sub-Saharan African country—the case of Tanzania. Cost Effectiveness and Resource Allocation 5:3. Rodriguez, A., F. Boullon, N. Perez-Balino, C. Paviotti, M. I. Liprandi, and I. F. Palacios. 1993. Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease (ERACI): In-hospital results and 1-year follow-up. Eraci group. Journal of the American College of Cardiology 22(4):1060-1067. Rossouw, J. E., P. L. Jooste, D. O. Chalton, E. R. Jordaan, M. L. Langenhoven, P. C. Jordaan, M. Steyn, A. S. Swanepoel, and L. J. Rossouw. 1993. Community-based interven- tion: The coronary risk factor study (CORIS). International Journal of Epidemiology 22(3):428-438. Roux, L., M. Pratt, T. O. Tengs, M. M. Yore, T. L. Yanagawa, J. Van Den Bos, C. Rutt, R. C. Brownson, K. E. Powell, G. Heath, H. W. Kohl, 3rd, S. Teutsch, J. Cawley, I. M. Lee, L. West, and D. M. Buchner. 2008. Cost-effectiveness of community-based physical activity interventions. American Journal of Preventive Medicine 35(6):578-588. Rubinstein, A., S. Garcia Marti, A. Souto, D. Ferrante, and F. Augustovski. 2009. Generalized cost-effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina. Cost Effectiveness and Resource Allocation 7(1):10. Salvetti, X. M., J. A. Oliveira, D. M. Servantes, and A. A. Vincenzo de Paola. 2008. How much do the benefits cost? Effects of a home-based training programme on cardiovascular fit- ness, quality of life, programme cost and adherence for patients with coronary disease. Clinical Rehabilitation 22(10-11):987-996. Schooler, C., J. W. Farquhar, S. P. Fortmann, and J. A. Flora. 1997. Synthesis of findings and issues from community prevention trials. Annals of Epidemiology 7(Suppl 1):S54-S68. Schwappach, D., T. Boluarte, and M. Suhrcke. 2007. The economics of primary prevention of cardiovascular disease—a systematic review of economic evaluations. Cost-Effectiveness and Resource Allocation 5(1):5. Shafiq, N., S. Malhotra, P. Pandhi, N. Sharma, A. Bhalla, and A. Grover. 2006. A randomized controlled clinical trial to evaluate the efficacy, safety, cost-effectiveness and effect on PAI-1 levels of the three low-molecular-weight heparins—enoxaparin, nadroparin and dalteparin. The ESCAPe-END study. Pharmacology 78(3):136-143. Shibuya, K., C. Ciecierski, E. Guindon, D. W. Bettcher, D. B. Evans, and C. J. L. Murray. 2003. WHO Framework Convention on Tobacco Control: Development of an evidence based global public health treaty. British Medical Journal 327(7407):154-157.

OCR for page 317
 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD Tang, J.-L., W.-Z. Wang, J.-G. An, Y.-H. Hu, S.-H. Cheng, and S. Griffiths. 2009. How willing are the public to pay for anti-hypertensive drugs for primary prevention of car- diovascular disease: A survey in a Chinese city. International Journal of Epidemiology 39(1):244-254. Thavorn, K., and N. Chaiyakunapruk. 2008. A cost-effectiveness analysis of a community pharmacist-based smoking cessation programme in Thailand. Tobacco Control 17(3): 177-182. Weinstein, M. C., B. O’Brien, J. Hornberger, J. Jackson, M. Johannesson, C. McCabe, and B. R. Luce. 2003. Principles of good practice for decision analytic modeling in health-care evaluation: Report of the ISPOR task force on good research practices modeling studies. Value in Health 6(1):9-17. Wessels, F. 2007. Eprosartan in secondary prevention of stroke: The economic evidence. Car- diovascular Journal of Africa 18(2):95-96. Whelton, P. K., J. He, and P. Muntner. 2004. Prevalence, awareness, treatment and control of hypertension in North America, North Africa and Asia. Journal of Human Hypertension 18(8):545-551. WHO (World Health Organization). 2006. WHO country health information. http://www. who.int/nha/country/en/ (accessed February 5, 2010). WHO. 2010. Choosing Interventions that are Cost-Effective (WHO-CHOICE). http://www. who.int/choice/en/ (accessed March 15, 2010).