title: Costs and Cost-Effectiveness of Hypertension Screening and Treatment in Adults with Hypertension in Rural Nigeria in the Context of a Health Insurance Program.
abstract: BACKGROUND
  High blood pressure is a leading risk factor for death and disability in sub-Saharan Africa (SSA). We evaluated the costs and cost-effectiveness of hypertension care provided within the Kwara State Health Insurance (KSHI) program in rural Nigeria.
  
  
  METHODS
  A Markov model was developed to assess the costs and cost-effectiveness of population-level hypertension screening and subsequent antihypertensive treatment for the population at-risk of cardiovascular disease (CVD) within the KSHI program. The primary outcome was the incremental cost per disability-adjusted life year (DALY) averted in the KSHI scenario compared to no access to hypertension care. We used setting-specific and empirically-collected data to inform the model. We defined two strategies to assess eligibility for antihypertensive treatment based on 1) presence of hypertension grade 1 and 10-year CVD risk of >20%, or grade 2 hypertension irrespective of 10-year CVD risk (hypertension and risk based strategy) and 2) presence of hypertension in combination with a CVD risk of >20% (risk based strategy). We generated 95% confidence intervals around the primary outcome through probabilistic sensitivity analysis. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the reference scenario.
  
  
  RESULTS
  Screening and treatment for hypertension was potentially cost-effective but the results were sensitive to changes in underlying assumptions with a wide range of uncertainty. The incremental cost-effectiveness ratio for the first and second strategy respectively ranged from US$ 1,406 to US$ 7,815 and US$ 732 to US$ 2,959 per DALY averted, depending on the assumptions on risk reduction after treatment and compared to no access to antihypertensive treatment.
  
  
  CONCLUSIONS
  Hypertension care within a subsidized private health insurance program may be cost-effective in rural Nigeria and public-private partnerships such as the KSHI program may provide opportunities to finance CVD prevention care in SSA.
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands.|Office of Public Health Studies, University of Hawaii, John A. Burns School of Medicine, 1960 East-West Road, Honolulu, HI, United States of America.
authors.forename: Nicole T A
authors.initials: NT
authors.lastname: Rosendaal
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands.
authors.forename: Marleen E
authors.initials: ME
authors.lastname: Hendriks
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Verhagen
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, P.M.B. 1459, Ilorin, postal code 240001, Nigeria.
authors.forename: Oladimeji A
authors.initials: OA
authors.lastname: Bolarinwa
authors.affiliation: Department of Medicine, University of Ilorin Teaching Hospital, P.M.B. 1459, Ilorin, postal code 240001, Nigeria.
authors.forename: Emmanuel O
authors.initials: EO
authors.lastname: Sanya
authors.affiliation: Department of Medicine, University of Ilorin Teaching Hospital, P.M.B. 1459, Ilorin, postal code 240001, Nigeria.
authors.forename: Philip M
authors.initials: PM
authors.lastname: Kolo
authors.affiliation: Hygeia Nigeria Ltd, 13B Idejo Street, Victoria Island, Lagos, Nigeria.
authors.forename: Peju
authors.initials: P
authors.lastname: Adenusi
authors.affiliation: Ogo Oluwa Hospital, Bacita, Kwara State, Nigeria.
authors.forename: Kayode
authors.initials: K
authors.lastname: Agbede
authors.affiliation: PharmAccess Foundation, Amsterdam, The Netherlands.
authors.forename: Diederik
authors.initials: D
authors.lastname: van Eck
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands.
authors.forename: Siok Swan
authors.initials: SS
authors.lastname: Tan
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, P.M.B. 1459, Ilorin, postal code 240001, Nigeria.
authors.forename: Tanimola M
authors.initials: TM
authors.lastname: Akande
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands.
authors.forename: William
authors.initials: W
authors.lastname: Redekop
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands.
authors.forename: Constance
authors.initials: C
authors.lastname: Schultsz
authors.affiliation: Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Pietersbergweg 17, Amsterdam, 1105 BM, The Netherlands.|Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Gabriela B
authors.initials: GB
authors.lastname: Gomez
mesh_terms: D000328:Adult; D000368:Aged; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000191:economics* / Q000453:epidemiology / Q000628:therapy; D007348:Insurance, Health / Q000191:economics* / Q000706:statistics & numerical data; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D018803:Models, Economic; D009549:Nigeria; D012424:Rural Population / Q000706:statistics & numerical data