Promoting Cardiovascular Health in the Developing World A Critical Challenge to Achieve Global Health (2010) / Chapter Skim
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7 Making Choices to Reduce the Burden of Cardiovascular Disease
7 Making Choices to Reduce the Burden of Cardiovascular Disease
Pages 317-372
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From page 317... ...
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.
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From page 318... ...
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.
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From page 319... ...
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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From page 320... ...
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.
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From page 321... ...
. Salt reduction through communication and mass media programs were deemed likely to be costeffective, 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)
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From page 322... ...
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 reviewed in Chapter 5, there are limitations on the available economic analyses.
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From page 323... ...
In addition, there has been limited economic evaluation of screening strategies, a necessary 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.
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From page 324... ...
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 approach 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.
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From page 325... ...
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 addition, 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 determine the total investment required to fill the treatment gap.
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From page 326... ...
. 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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From page 327... ...
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.
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From page 328... ...
Based on a meta-analysis of published articles on nationally representative health surveys, Table 7.2 shows the prevalence, awareness, treatment, and control rates for hypertension in adult populations across 9 developing countries, including at least 1 country in each of the World Health Organization Developing World Regions, as well as in the United States as a comparison. Overall, control of hypertension is poor, with most countries having control rates of less than 15 percent.
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From page 329... ...
in 2008 and as a percentage of the nation's total health expenditures in 2006. The estimated costs relative to both GDP and total health expenditures show considerable variability across countries, with India and Chile standing out at the high end of the range.
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From page 330... ...
Successfully filling the treatment gap for hypertension could also potentially produce cost savings in the longer term by reducing not only the burden of CVD but also the burden of complications of other chronic diseases, such as diabetes and kidney failure. This analysis provided an example of country-specific analyses of one risk factor for CVD.
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From page 331... ...
. Given the growing importance of CVD and other chronic diseases in developing countries, and the potential to seriously thwart or delay economic development -- further research will be critical to determine, for specific countries, which investments are needed to address CVD and which investments are likely to produce the highest returns.
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From page 332... ...
This is because there is a lack of primary economic analyses in developing countries, variation in costs and population health across countries, and reason to question whether and how the evidencebased strategies to prevent and manage CVD that have been shown to be cost-effective in developed countries are applicable in a developing-country context where resources are more limited and health care systems are less strong and more variable. The available research studies are biased toward individual interventions, mostly pharmaceutical, targeted at persons with already established risk factors.
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From page 333... ...
The predominance of the use of developed-country effectiveness data in these models is due primarily to the lack of effectiveness data for CVD interventions in developing countries, as has been described in Chapters 5 and 6. Efforts to fill this knowledge gap will also serve to improve the quality of economic analyses by making more relevant secondary data available.
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From page 334... ...
In both reviews commissioned by this committee, for example, the authors found that there was a lack of full information in many modeling studies. Increasing the Evidence Base of Primary Economic Analyses of Interventions Conducted in Developing-Country Settings Modeling methodologies to transfer results from developed to developing countries and between developing countries will continue to be an important approach to assessing the most cost-effective ways to address CVD.
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From page 335... ...
Key perspectives that are relevant to policy makers include, for example, the health care provider, the patient, the government, third-party payers, and the societal perspective, which has not yet been explicitly applied to the evaluation of interventions for CVD in the developing world. Defining Resource Needs As described in this chapter, there has not been sufficient analysis to determine what it will cost to reduce the burden of CVD in developing countries.
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From page 336... ...
Further work should be conducted into investigating the broader determinants of treatment gaps because they are crucial in establishing any policy response. Second, existing evidence of treatment gaps generally focuses on a single risk factor.
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From page 337... ...
These include staretegies for tobacco control, reduction of salt in the food supply and in consumption, and improved delivery of clinical prevention using pharmaceutical interventions in high-risk patients, especially if linked to existing health systems strengthening efforts. The evidence for lowered CVD morbidity associated with achieving these priority goals is credible, there are examples of successful implementation of programs in each of these focus areas with the potential to be adapted for low and middle income countries, and economic analyses have shown that they are likely to be cost-effective.
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From page 338... ...
b For tobacco control, see also reviews by Chisholm et al., 2006; Jha et al., 2006; and Shibuya et al., 2003.
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From page 339... ...
WHO CHOICE Assumed 3.4% decline in ICER: Y Modeling tobacco consumption PLUS 304 EEK/DALY 5% decline in new smokers WHO CHOICE Assumed 3.4% decline in ICER: Y Modeling tobacco consumption PLUS 453 EEK/DALY 5% decline in new smokers PLUS 5% decline in the incidence of smoking among male smokers, and 2.4% decline among female smokers Modeling Assumed a reduction in future ICER: Not reported tobacco deaths of 5.4%-15.9% US$2-26/DALY Modeling Assumed a reduction in future ICER: Not reported tobacco deaths of 1.6%-7.9% US$33-417/DALY Modeling Assumed a 14.3% smoking Cost savings of Y cessation rate (with no relapse) 17503 baht (£250; with a corresponding assumed €325; US$500)
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From page 340... ...
0 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD TABLE 7.5a Continued Intervention Country/ Type Reference Setting Intervention Comparator Food Regulation Rubinstein et al., Argentina Regulation of salt Null 2009 (Buenos content of bread Aires) Murray et al., Latin Salt reduction -- Null 2003 America industry agreements Latin Salt reduction -- Null America legislation South-East Salt reduction -- Null Asia industry agreements South-East Salt reduction -- Null Asia legislation Gaziano, 2008 Sub-Saharan Substitution of Null Africa polyunsaturated fats for 2% of dietary transfats Physical Activity Matsudo et al., Brazil Population-based 2006 physical activity promotion
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From page 341... ...
reduction per 100g of bread led 151 ARG$/DALY to a reduction of 1.33mmHg per capita GNI in systolic blood pressure per person and 1% of the population-attributable risk of CHD and stroke Popmod multi- Assumed blood pressure Average CER: Y state modeling changes specific for region, age, US$24/DALY based on < per and sex associated with a 15% capita GDP reduction in total dietary salt intake Popmod multi- Assumed blood pressure Average CER: Y state modeling changes specific for region, age, US$13/DALY and sex associated with a 30% reduction in total dietary salt intake Popmod multi- Assumed blood pressure Average CER: Y state modeling changes specific for region, age, US$37/DALY and sex associated with a 15% reduction in total dietary salt intake Popmod multi- Assumed blood pressure Average CER: Y state modeling changes specific for region, age, US$19/DALY and sex associated with a 30% reduction in total dietary salt intake Popmod multi- Assumed reduction in CAD of ICER: Y state modeling 7% to 40% US$53-1344/ DALY at 7% Cost saving US$ –184 at 40% Modeling Assumptions for model Cost Utility Y unknown Analysis: Cost saving continued
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From page 342... ...
PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD TABLE 7.5a Continued Intervention Country/ Type Reference Setting Intervention Comparator Physical Salvetti et al., Brazil Home-based training Standard care Activity 2008 for physical post-MI (cont.) Health Education Murray et al., South-East Health education Null 2003 Asia focusing on lowering BMI and cholesterol Latin Health education Null America focusing on lowering BMI and cholesterol Getpreechaswas Thailand Social marketing Interview only et al., 2007 through trained health personnel, village health volunteers, and family health leaders García-Peña et Mexico Health education in No intervention al., 2002 home visits by nurse to elderly people with hypertension
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From page 343... ...
and self-reported measures per patient for 3 of quality of life improved in months the intervention group and remained constant or worsened in the control group Popmod multi- Assumed a 2% reduction Average CER: Y state modeling in total blood cholesterol US$14/DALY based on < per concentrations capita GDP Popmod multi- Assumed a 2% reduction Average CER: Y state modeling in total blood cholesterol US$14/DALY concentrations Observational The intervention group showed Costs: 74.89 Not reported trial a significant improvement baht per head of in dietary patters, physical population activity, and stress reduction and a significant decrease in tobacco and alcohol use compared to the control group RCT A reduction of 3.31 mm Hg CER: Not possible in SBP and 3.67 mm Hg in 10.46 pesos to conclude DBP in the intervention group (US$1.14) per compared to the control group.
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From page 344... ...
Rubinstein et al., Argentina Health education Null 2009 (Buenos through mass media Aires) Rossouw et al., South Africa Social Marketing No intervention 1993 (CORIS)
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From page 345... ...
Modelling Assume a reduction of ICER: Y Based on <3× Popmod 1.83mmHg in systolic blood 547 ARG$/DALY (WHO) pressure and 0.02mm/l in per capita GNI cholesterol (t)
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From page 346... ...
PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD TABLE 7.5a Continued Intervention Country/ Type Reference Setting Intervention Comparator Multiple Asaria et al., Multi- Population-based No treatment Strategies 2007 national strategies to reduce salt consumption by 15% and a 43.2% increase in the price of tobacco combined with non-price interventions NOTE: AMI = Acute Myocardial Infarction; CAD = Coronary Artery Disease; CER = CostEffectiveness Ratio; CHD = Coronary Heart Disease; CHF = Congestive Heart Failure; COPD = Chronic Obstructive Pulmonary Disease; CVD = Cardiovascular Disease; DALY = DisabilityAdjusted Life Year; GDP = Gross Domestic Product; GNI = Gross National Income; ICER = Incremental Cost-Effectiveness Ratio; RCT = Randomized Controlled Trial; WHO = World Health Organization.
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From page 347... ...
MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis Cost Methoda Assumed Outcomea Resulta Effective? Modeling Salt Reduction Costs range from Not reported Assumed the reduction in salt US$0.14-1.04 intake lead to an age-stratified per person per decrease in mmHg of SPB of year to avert 1.24 (30-44)
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From page 348... ...
South Asia Secondary prevention Null (aspirin, β-blockers, ACE-inhibitor, statins) aSources 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.
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From page 349... ...
MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis CostMethodologya Assumed Outcomea Resulta Effective? Modeling Assumed achievement of a Financial resources Not reported 50% drug coverage rate in the needed to scale up more constrained countries average $5 billion per Assumed achievement of an year, or $1.08 per head 80% coverage rate in the less per year constrained countries Assumed between 40% and 60% drug adherence Markov model Assumed a 7% reduction in ICER: US$336/QALY Y based on <3× lifetime risk for CVD per capita GNI Markov model Assumed a 15% reduction in ICER: US$362/QALY Y lifetime risk for CVD Markov model Assumed a 12% reduction in ICER: US$388/QALY Y lifetime risk for CVD Markov model Assumed a 15% reduction in ICER: US$341/QALY Y lifetime risk for CVD Markov model Assumed a 13% reduction in ICER: US$306/QALY Y lifetime risk for CVD continued
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From page 350... ...
East Europe Primary prevention Null and Central absolute risk 5% and Asia 25% (aspirin, calcium channel blocker, ACE inhibito, statin) Latin America Primary prevention Null and Caribbean absolute risk 5% and 25% (aspirin, calcium channel blocker, ACE inhibitor, statin)
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From page 351... ...
MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis CostMethodologya Assumed Outcomea Resulta Effective? Markov model Assumed a 9% reduction in ICER: US$312/QALY Y lifetime risk for CVD Markov model Assumed a 54% and 40% ICER: Y reduction in lifetime risk for US$1214/QALY CVD US$890/QALY Markov model Assumed a 43% and 30% ICER: Y reduction in lifetime risk for US$1207/QALY CVD US$858/QALY Markov model Assumed a 53% and 32% ICER: Y reduction in lifetime risk for US$1219/QALY CVD US$881/QALY Markov model Assumed a 50% and 29% ICER: Y reduction in lifetime risk for US$1221/QALY CVD US$872/QALY Markov model Assumed a 50% and 27% ICER: Y reduction in lifetime risk for US$1039/QALY CVD US$746/QALY Markov model Assumed a 59% and 32% ICER: Y reduction in lifetime risk for US$1145/QALY CVD US$771/QALY Other Blood pressure control was Most cost-effective See achieved in 39.6% of the was coamiloride with comparison target population CER 42.9, least was result combination CCB with ACEI, CER 3145.2 continued
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From page 352... ...
three different target populations (risk determined with Framingham equations) 20% CVD risk Argentina As above -- 10% CVD Null (Buenos Aires)
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From page 353... ...
MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis CostMethodologya Assumed Outcomea Resulta Effective? Modeling Assumed that 40% of the ICER: N Popmod population would take one 7716 ARG$/DALY (WHO)
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From page 354... ...
Not risk targeted Tanzania Aspirin, diuretic, Null β-blocker; Not risk targeted Tanzania Aspirin, diuretic, Null β-blocker, statin; Not risk targeted Tanzania Hypothetical polypill; Null Not risk targeted Moreira et al., Brazil Treatment of Null 2009 hypertension with diuretics Brazil Treatment of Null hypertension with β-blockers Brazil Treatment of Null hypertension with ACEI Gaziano, 2005 South Africa Targeted drug treatment No based on blood pressure treatment 160/95mmHg South Africa Targeted drug treatment No based on blood pressure treatment 140/90mmHg
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From page 355... ...
Observational Observed a 66.4% blood Average CER: Not reported cohort >40 pressure control rate US$34.7 years Observational Observed a 44.8% blood Average CER: Not reported cohort >40 pressure control rate US$176.7 years Markov CVD Treatment was assumed to Dominated N model lead to a 10mmHg reduction in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD Markov CVD Treatment was assumed to Dominated N model lead to a 10mmHg reduction in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD continued
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From page 356... ...
based on 10-year treatment absolute CVD risk >40% South Africa Targeted drug treatment Treatment based on 10-year at 40% risk absolute CVD risk >30% South Africa Targeted drug treatment Treatment based on 10-year at 30% risk absolute CVD risk >20% South Africa Targeted drug treatment Treatment based on 10-year at 20% risk absolute CVD risk >15% Shafiq et al., India Low molecular weight No 2006 heparin in patients with treatment unstable angina Murray et al., Latin America Hypertension treatment No (β-blocker, diuretic) and 2003 treatment education; Not risk targeted
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From page 357... ...
14% relative risk reduction for CHD Markov CVD Treatment was assumed to ICER: Y model lead to a 10mmHg reduction US$1600/QALY in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD Markov CVD Treatment was assumed to ICER: Y model lead to a 10mmHg reduction US$4900/QALY in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD Markov CVD Treatment was assumed to ICER: N model lead to a 10mmHg reduction US$11000/QALY in SDP, which was assumed to lead to a 40% relative risk reduction for stroke and a 14% relative risk reduction for CHD Prospective Primary endpoints of death, ICER: See RCT MI, or angina occurred in US$54.72 to US$119.91/ comparison 24% to 30% of patients composite endpoint result Popmod multi- Assumed a 33% reduction in Average CER: N state modeling difference between the actual US$81/DALY Based on < per SBP and 115mm Hg capita GDP continued
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From page 358... ...
and treatment education; Not risk targeted South-East Blood pressure and No Asia cholesterol treatment treatment and education; Not risk targeted South-East Treatment based on No Asia absolute risk (>35% risk treatment in 10 years) Ker et al., South Africa Pharmaceutical No 2008 interventions with treatment tobacco cessation
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From page 359... ...
MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis CostMethodologya Assumed Outcomea Resulta Effective? Popmod multi- Assumed a 20% reduction in Average CER: N state modeling total blood cholesterol US$87/DALY Popmod multi- Assumed a 33% reduction in Average CER: N state modeling difference between the actual US$183/DALY SBP and 115mmHg and a 20% reduction in total blood cholesterol Popmod multi- Assumed a 33% reduction Average CER: Y state modeling in difference between the US$37/DALY actual SBP and 115mmHg, a 20% reduction in total blood cholesterol, and an additional 20% reduction of absolute risk for antiplatelet therapy Popmod multi- Assumed a 33% reduction in Average CER: state modeling difference between the actual US$36/DALY N SBP and 115mmHg Popmod multi- Assumed a 20% reduction in Average CER: N state modeling total blood cholesterol US$47/DALY Popmod multi- Assumed a 33% reduction in Average CER: N state modeling difference between the actual US$84/DALY SBP and 115mmHg and a 20% reduction in total blood cholesterol Popmod multi- Assumed a 33% reduction Average CER: Y state modeling in difference between the US$33/DALY actual SBP and 115mmHg, a 20% reduction in total blood cholesterol, and an additional 20% reduction of absolute risk for antiplatelet therapy Modeling Assumed an absolute risk Costs per % of risk Not reported reduction of 7% to 22% reduction ranges from R12.7 to R23.84 continued
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From page 360... ...
therapy (bupropion) Redekop et al., Poland Prevention of CVD Placebo 2008 endpoints with perindopril in CHD patients Wessels, 2007 South Africa Prevention of Use of cardiovascular or amlodipine cerebrovascular events and with eprosartan in perindopril stroke patients Dias da Costa Brazil Treatment of Alternative et al., 2002 hypertension with drugs diuretics, β-blockers, calcium channel blockers, and ACE-inhibitors Anderson et South Africa Treatment with Alternative al., 2000 angiotensin II type 1 drugs receptor blockers in patients with mild to moderate hypertension
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From page 361... ...
MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis CostMethodologya Assumed Outcomea Resulta Effective? Modeling Assumed a reduction of 4% ICER: N Popmod of the population-attributable 33563 ARG$/DALY (WHO)
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From page 362... ...
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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From page 363... ...
MAKING CHOICES TO REDUCE THE BURDEN Outcome or Economic Analysis CostMethodologya 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)
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From page 364... ...
acute MI Health Care Delivery Diaz et al., Chile Stroke unit Regular 2006 hospital care
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From page 365... ...
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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From page 366... ...
NOTE: ACE-inhibitor = Angiotensin converting enzyme inhibitor; AMI = Acute Myocardial Infarction; CABG = Coronary Artery Bypass Graft; CBV = Cerebrovascular; CER = CostEffectiveness 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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From page 367... ...
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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From page 368... ...
2005. Cardiovascular disease in the developing world and its cost-effective management.
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From page 369... ...
. A review of the evidence on treatment gaps, costs and cost-effectiveness of interventions for the prevention of cardiovascular disease in developing countries.
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From page 370... ...
2007. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: Health effects and costs.
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From page 371... ...
2007. The economics of primary prevention of cardiovascular disease -- a systematic review of economic evaluations.
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From page 372... ...
2007. Eprosartan in secondary prevention of stroke: The economic evidence.
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