title: Cost-effectiveness of medical primary prevention strategies to reduce absolute risk of cardiovascular disease in Tanzania: a Markov modelling study.
abstract: Cardiovascular disease (CVD) is a growing cause of mortality and morbidity in Tanzania, but contextualized evidence on cost-effective medical strategies to prevent it is scarce. We aim to perform a cost-effectiveness analysis of medical interventions for primary prevention of CVD using the World Health Organization's (WHO) absolute risk approach for four risk levels.
  
  
  
  The cost-effectiveness analysis was performed from a societal perspective using two Markov decision models: CVD risk without diabetes and CVD risk with diabetes. Primary provider and patient costs were estimated using the ingredients approach and step-down methodologies. Epidemiological data and efficacy inputs were derived from systematic reviews and meta-analyses. We used disability- adjusted life years (DALYs) averted as the outcome measure. Sensitivity analyses were conducted to evaluate the robustness of the model results.
  
  
  
  For CVD low-risk patients without diabetes, medical management is not cost-effective unless willingness to pay (WTP) is higher than US$1327 per DALY averted. For moderate-risk patients, WTP must exceed US$164 per DALY before a combination of angiotensin converting enzyme inhibitor (ACEI) and diuretic (Diu) becomes cost-effective, while for high-risk and very high-risk patients the thresholds are US$349 (ACEI, calcium channel blocker (CCB) and Diu) and US$498 per DALY (ACEI, CCB, Diu and Aspirin (ASA)) respectively. For patients with CVD risk with diabetes, a combination of sulfonylureas (Sulf), ACEI and CCB for low and moderate risk (incremental cost-effectiveness ratio (ICER) US$608 and US$115 per DALY respectively), is the most cost-effective, while adding biguanide (Big) to this combination yielded the most favourable ICERs of US$309 and US$350 per DALY for high and very high risk respectively. For the latter, ASA is also part of the combination.
  
  
  
  Medical preventive cardiology is very cost-effective for all risk levels except low CVD risk. Budget impact analyses and distributional concerns should be considered further to assess governments' ability and to whom these benefits will accrue.
authors.affiliation: Ministry of Health and Social Welfare, Dar es Salaam, Tanzania. frida.ngalesoni@igs.uib.no.|Department of Global Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, Post box 7804, NO-5020, Bergen, Norway. frida.ngalesoni@igs.uib.no.
authors.forename: Frida N
authors.initials: FN
authors.lastname: Ngalesoni
authors.affiliation: Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.|Department of Global Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, Post box 7804, NO-5020, Bergen, Norway.
authors.forename: George M
authors.initials: GM
authors.lastname: Ruhago
authors.affiliation: Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.|Centre of International Health, University of Bergen, Bergen, Norway.
authors.forename: Amani T
authors.initials: AT
authors.lastname: Mori
authors.affiliation: Centre of International Health, University of Bergen, Bergen, Norway.
authors.forename: Bjarne
authors.initials: B
authors.lastname: Robberstad
authors.affiliation: Department of Global Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, Post box 7804, NO-5020, Bergen, Norway.
authors.forename: Ole F
authors.initials: OF
authors.lastname: Norheim
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics / Q000627:therapeutic use; D001241:Aspirin / Q000191:economics / Q000627:therapeutic use; D002121:Calcium Channel Blockers / Q000191:economics / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000191:economics / Q000517:prevention & control*; D003362:Cost-Benefit Analysis; D003925:Diabetic Angiopathies / Q000191:economics / Q000517:prevention & control; D005260:Female; D006801:Humans; D008297:Male; D015201:Meta-Analysis as Topic; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D011322:Primary Prevention / Q000191:economics; D019057:Quality-Adjusted Life Years; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment / Q000191:economics / Q000379:methods; D040242:Risk Reduction Behavior; D013636:Tanzania; D016896:Treatment Outcome
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D002121:Calcium Channel Blockers; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin
keywords: Cardiovascular disease; Cost-effectiveness analysis; Diabetes; Markov modelling; Primary prevention; Societal perspective; Sub-Saharan Africa; Tanzania